Healthcare Provider Details

I. General information

NPI: 1699323576
Provider Name (Legal Business Name): CHARITY KEONNA HALLER DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2019
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29645 RANCHO CALIFORNIA RD STE 201
TEMECULA CA
92591-5285
US

IV. Provider business mailing address

12010 CAMINITO CAMPANA
SAN DIEGO CA
92128-2014
US

V. Phone/Fax

Practice location:
  • Phone: 951-676-1480
  • Fax:
Mailing address:
  • Phone: 716-860-6822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDB-2024-0058
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: