Provider Demographics
NPI:1821616806
Name:HALL, DERRICK L (RDA)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:L
Last Name:HALL
Suffix:
Gender:M
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E AVENUE R APT 9102
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93550-2611
Mailing Address - Country:US
Mailing Address - Phone:818-237-8080
Mailing Address - Fax:
Practice Address - Street 1:22800 LYONS AVE STE 200
Practice Address - Street 2:
Practice Address - City:NEWHALL
Practice Address - State:CA
Practice Address - Zip Code:91321-2898
Practice Address - Country:US
Practice Address - Phone:818-237-8080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-07
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA70848126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant