Provider Demographics
NPI:1912015793
Name:HALL, NATHANIEL CARSON (DMD)
Entity Type:Individual
Prefix:DR
First Name:NATHANIEL
Middle Name:CARSON
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 1:908 PALM BLVD S
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-2603
Mailing Address - Country:US
Mailing Address - Phone:850-729-1223
Mailing Address - Fax:850-678-6086
Practice Address - Street 1:908 PALM BLVD S
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-2603
Practice Address - Country:US
Practice Address - Phone:850-729-1223
Practice Address - Fax:850-678-6086
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN175321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
809857OtherUNITED CONCORDIA
FL87406OtherBLUE CROSS OF FLORIDA