Provider Demographics
NPI:1720187750
Name:HALL, JOHN LEGLAGEN (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:LEGLAGEN
Last Name:HALL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3359 HARTLEY DRIVE
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221
Mailing Address - Country:US
Mailing Address - Phone:517-862-1590
Mailing Address - Fax:
Practice Address - Street 1:3359 HARTLEY DRIVE
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221
Practice Address - Country:US
Practice Address - Phone:517-862-1590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010168961223D0001X
IL019.0231971223G0001X
IN12011912A1223G0001X
OH30.0206191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201134060Medicaid
OH0317521Medicaid
MI420322612Medicaid