Healthcare Provider Details

I. General information

NPI: 1841923281
Provider Name (Legal Business Name): HALEY DIETZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2022
Last Update Date: 07/04/2022
Certification Date: 07/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 NW 1ST ST # 120
BATTLE GROUND WA
98604-4540
US

IV. Provider business mailing address

638 NE 79TH AVE
PORTLAND OR
97213-6913
US

V. Phone/Fax

Practice location:
  • Phone: 360-666-5700
  • Fax:
Mailing address:
  • Phone: 540-392-1820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number61314756
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: