Provider Demographics
NPI:1780713537
Name:HALL, RICHARD KEITH (DDS)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:KEITH
Last Name:HALL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:RICHARD
Other - Middle Name:K
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:3443 LAKE TAHOE BVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150
Mailing Address - Country:US
Mailing Address - Phone:530-544-3426
Mailing Address - Fax:530-542-7710
Practice Address - Street 1:3443 LAKE TAHOE BVD
Practice Address - Street 2:SUITE B
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150
Practice Address - Country:US
Practice Address - Phone:530-544-3426
Practice Address - Fax:530-542-7710
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28324122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist