Healthcare Provider Details

I. General information

NPI: 1407775893
Provider Name (Legal Business Name): NICOLE MARIE HALATSIS DDS
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 DAHLIA LN
ROCHESTER HILLS MI
48307-3300
US

IV. Provider business mailing address

840 DAHLIA LN
ROCHESTER HILLS MI
48307-3300
US

V. Phone/Fax

Practice location:
  • Phone: 586-944-5093
  • Fax:
Mailing address:
  • Phone: 586-944-5093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901603205
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: