Provider Demographics
NPI:1790229383
Name:HALES DENTAL PRACTICE, PC
Entity Type:Organization
Organization Name:HALES DENTAL PRACTICE, PC
Other - Org Name:ANGELLIFT DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:B
Authorized Official - Last Name:HALES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:541-474-1100
Mailing Address - Street 1:781 NE 7TH ST
Mailing Address - Street 2:B
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1654
Mailing Address - Country:US
Mailing Address - Phone:541-474-1100
Mailing Address - Fax:541-474-1103
Practice Address - Street 1:781 NE 7TH ST
Practice Address - Street 2:B
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1654
Practice Address - Country:US
Practice Address - Phone:541-474-1100
Practice Address - Fax:541-474-1103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-15
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD6777261QD0000X, 305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR6080140001OtherMEDICARE DME PTAN
OR040241Medicaid