Provider Demographics
NPI:1427556984
Name:VAN HALA DENTAL GROUP LLC
Entity type:Organization
Organization Name:VAN HALA DENTAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:ADDISON
Authorized Official - Last Name:VAN HALA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:330-494-0646
Mailing Address - Street 1:1515 PORTAGE ST NW # 1
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-2290
Mailing Address - Country:US
Mailing Address - Phone:330-494-0646
Mailing Address - Fax:
Practice Address - Street 1:1515 PORTAGE ST NW # 1
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-2290
Practice Address - Country:US
Practice Address - Phone:330-494-0646
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-30
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30022586122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty