Healthcare Provider Details

I. General information

NPI: 1558379743
Provider Name (Legal Business Name): GARY M HALLER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 12/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 SOUTH GREEN RIVER ROAD
EVANSVILLE IN
47715
US

IV. Provider business mailing address

207 SOUTH GREEN RIVER ROAD
EVANSVILLE IN
47715
US

V. Phone/Fax

Practice location:
  • Phone: 812-476-3131
  • Fax: 812-476-6621
Mailing address:
  • Phone: 812-476-3131
  • Fax: 812-476-6621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7860
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: