1699323576 NPI number — DR. CHARITY KEONNA HALLER DMD

Table of content: DR. CHARITY KEONNA HALLER DMD (NPI 1699323576)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699323576 NPI number — DR. CHARITY KEONNA HALLER DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HALLER
Provider First Name:
CHARITY
Provider Middle Name:
KEONNA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699323576
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/24/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
31 HITREE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14624-4740
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-860-6822
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
310 CONTINENTAL DRIVE
Provider Second Line Business Practice Location Address:
SUTIE 106
Provider Business Practice Location Address City Name:
JAL
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88252-2525
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
753-952-2095
Provider Business Practice Location Address Fax Number:
575-395-2205
Provider Enumeration Date:
09/03/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: DB-2024-0058 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com