Basic Information
Provider Information | |||||||||
NPI: | 1770145716 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GULLEY | ||||||||
FirstName: | HALIE | ||||||||
MiddleName: | FAYE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DDS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MOITOZA | ||||||||
OtherFirstName: | HALIE | ||||||||
OtherMiddleName: | FAYE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DDS | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3009 HWY K | ||||||||
Address2: |   | ||||||||
City: | O'FALLON | ||||||||
State: | MO | ||||||||
PostalCode: | 63368 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6363797552 | ||||||||
FaxNumber: | 6363797553 | ||||||||
Practice Location | |||||||||
Address1: | 3009 HWY K | ||||||||
Address2: |   | ||||||||
City: | O'FALLON | ||||||||
State: | MO | ||||||||
PostalCode: | 63368 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6363797552 | ||||||||
FaxNumber: | 6363797553 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/29/2019 | ||||||||
LastUpdateDate: | 08/19/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/19/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 2019046179 | MO | N |   | Dental Providers | Dentist | General Practice | 122300000X | 61666 | KS | Y |   | Dental Providers | Dentist |   |
No ID Information.