Provider Demographics
NPI:1912569492
Name:HALE FAMILY DENTISTRY CORP
Entity Type:Organization
Organization Name:HALE FAMILY DENTISTRY CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:HALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-482-3759
Mailing Address - Street 1:4116 E STATE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-6977
Mailing Address - Country:US
Mailing Address - Phone:260-482-3759
Mailing Address - Fax:260-482-3750
Practice Address - Street 1:4116 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-6977
Practice Address - Country:US
Practice Address - Phone:260-482-3759
Practice Address - Fax:260-846-6641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-03
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300067224Medicaid