MEDICARE: MRS. AUTUMN JEAN HALEY DENTAL ASSISTANT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	126800000X	Dental Assistant

General Provider Information

NPI Number	:	1497193494
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AUTUMN JEAN HALEY DENTAL ASSISTANT

Provider Business Mailing Address
First Line	:	150 AMBERWOOD DR
Second Line	:
City	:	FORT STEWART
State	:	GA
Zip	:	31315-1780
Country	:	US
Telephone Number	:	970-310-4629
Fax Number	:

Provider Business Practice Location Address
First Line	:	150 AMBERWOOD DR
Second Line	:
City	:	FORT STEWART
State	:	GA
Zip	:	31315-1780
Country	:	US
Telephone Number	:	970-310-4629
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/12/2013
Last Update Date	:	06/12/2013

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