Provider Demographics
NPI:1679666234
Name:HALL, MARK M (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:M
Last Name:HALL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 MEADOW MOOR WAY
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:IN
Mailing Address - Zip Code:47446-1057
Mailing Address - Country:US
Mailing Address - Phone:812-849-5135
Mailing Address - Fax:
Practice Address - Street 1:1504 DENTAL DR
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:IN
Practice Address - Zip Code:47421-3574
Practice Address - Country:US
Practice Address - Phone:812-275-7975
Practice Address - Fax:812-275-7244
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120077881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice