Basic Information
Provider Information | |||||||||
NPI: | 1558802280 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VAN WINKLE | ||||||||
FirstName: | HALEY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 670 9TH ST STE 203 | ||||||||
Address2: |   | ||||||||
City: | ARCATA | ||||||||
State: | CA | ||||||||
PostalCode: | 955216249 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7078268633 | ||||||||
FaxNumber: | 7078268638 | ||||||||
Practice Location | |||||||||
Address1: | 550 E WASHINGTON BLVD STE 100 | ||||||||
Address2: |   | ||||||||
City: | CRESCENT CITY | ||||||||
State: | CA | ||||||||
PostalCode: | 955318161 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7074654636 | ||||||||
FaxNumber: | 7074656070 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/14/2017 | ||||||||
LastUpdateDate: | 12/02/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/02/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 105483 | CA | Y |   | Dental Providers | Dentist | General Practice |
No ID Information.