Provider Demographics
NPI:1063892313
Name:HALLIE, JON (DDS)
Entity type:Individual
Prefix:DR
First Name:JON
Middle Name:
Last Name:HALLIE
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 1:201 4TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ROSEAU
Mailing Address - State:MN
Mailing Address - Zip Code:56751-1033
Mailing Address - Country:US
Mailing Address - Phone:218-463-2553
Mailing Address - Fax:218-463-9464
Practice Address - Street 1:201 4TH AVE NW
Practice Address - Street 2:
Practice Address - City:ROSEAU
Practice Address - State:MN
Practice Address - Zip Code:56751-1033
Practice Address - Country:US
Practice Address - Phone:218-463-2553
Practice Address - Fax:218-463-9464
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13518122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist