Provider Demographics
NPI:1053358366
Name:HALL, KENNETH BRADLEY (DMD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:BRADLEY
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 1:1360 CADUCEUS WAY
Mailing Address - Street 2:BLDG 900 STE 101
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-7300
Mailing Address - Country:US
Mailing Address - Phone:706-543-3629
Mailing Address - Fax:706-543-5107
Practice Address - Street 1:1360 CADUCEUS WAY
Practice Address - Street 2:BLDG 900 STE 101
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-7300
Practice Address - Country:US
Practice Address - Phone:706-543-3629
Practice Address - Fax:706-543-5107
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN012753122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZG2753Medicaid
GA399593491AMedicaid