Provider Demographics
NPI:1730340837
Name:HALL, DUSTIN JORDAN (DMD)
Entity type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:JORDAN
Last Name:HALL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6045 KENTUCKY DAM RD
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-9472
Mailing Address - Country:US
Mailing Address - Phone:270-898-6215
Mailing Address - Fax:270-898-6504
Practice Address - Street 1:6045 KENTUCKY DAM RD
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-9472
Practice Address - Country:US
Practice Address - Phone:270-898-6215
Practice Address - Fax:270-898-6504
Is Sole Proprietor?:No
Enumeration Date:2008-06-20
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY84091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice