Provider Demographics
NPI:1366514135
Name:HALL, JOHN REAGAN (DMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:REAGAN
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 1:2216 17TH ST
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2901
Mailing Address - Country:US
Mailing Address - Phone:228-863-1911
Mailing Address - Fax:228-863-9211
Practice Address - Street 1:2216 17TH ST
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2901
Practice Address - Country:US
Practice Address - Phone:228-863-1911
Practice Address - Fax:228-863-9211
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2761-93122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist