Provider Demographics
NPI:1073335998
Name:MONTEBLANCO, HALEY
Entity type:Individual
Prefix:
First Name:HALEY
Middle Name:
Last Name:MONTEBLANCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7201 N INTERSTATE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-5523
Mailing Address - Country:US
Mailing Address - Phone:800-813-9721
Mailing Address - Fax:
Practice Address - Street 1:7201 N INTERSTATE AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-5523
Practice Address - Country:US
Practice Address - Phone:800-813-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant