Provider Demographics
NPI:1548387699
Name:HALLAS, PETER GARDNER (DDS)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:GARDNER
Last Name:HALLAS
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 1:2150 LAKE MICHIGAN DRIVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504
Mailing Address - Country:US
Mailing Address - Phone:616-453-8211
Mailing Address - Fax:616-453-3277
Practice Address - Street 1:2150 LAKE MICHIGAN DRIVE NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504
Practice Address - Country:US
Practice Address - Phone:616-453-8211
Practice Address - Fax:616-453-3277
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI140861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice