Basic Information
| Provider Information | |||||||||
| NPI: | 1760798730 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALL | ||||||||
| FirstName: | JESSE | ||||||||
| MiddleName: | PARK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | USA DENTAL ACTIVITY | ||||||||
| Address2: | B 2817 REILLY ROAD | ||||||||
| City: | FORT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283107302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106432196 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | USA DENTAL ACTIVITY | ||||||||
| Address2: | B 2817 REILLY ROAD | ||||||||
| City: | FORT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283107302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106432196 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2010 | ||||||||
| LastUpdateDate: | 08/26/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 6603-15 | WI | Y | Dental Providers | Dentist |
No ID Information.