Provider Demographics
NPI:1760916092
Name:HALL, MICHAEL CORY (DMD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:CORY
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 1:503 W MARTINTOWN ROAD
Mailing Address - Street 2:
Mailing Address - City:NORTH AUGUSTA
Mailing Address - State:SC
Mailing Address - Zip Code:29841
Mailing Address - Country:US
Mailing Address - Phone:803-278-2223
Mailing Address - Fax:803-278-2636
Practice Address - Street 1:503 W MARTINTOWN ROAD
Practice Address - Street 2:
Practice Address - City:NORTH AUGUSTA
Practice Address - State:SC
Practice Address - Zip Code:29841
Practice Address - Country:US
Practice Address - Phone:803-278-2223
Practice Address - Fax:803-278-2636
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-13
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN015458122300000X
390200000X
SC9132122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program