Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 22DIO13411800 | NJ |
NPI | 1043336597 |
---|---|
Provider Name | Mr. Lonnie Bruce Hall I |
First Address | West New York, NJ 07093-5497 |
Second Address | West New York, NJ 07093-5497 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/03/2007 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0845108 | (05) | NJ |