Provider Demographics
NPI:1215691985
Name:FLAKE, HALLEY ROSE (DDS)
Entity type:Individual
Prefix:DR
First Name:HALLEY
Middle Name:ROSE
Last Name:FLAKE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1053 GOLDEN PHEASANT DR
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-9260
Mailing Address - Country:US
Mailing Address - Phone:503-956-2655
Mailing Address - Fax:
Practice Address - Street 1:1745 EASTLAKE PKWY STE 102
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91915-2033
Practice Address - Country:US
Practice Address - Phone:619-421-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-28
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS107049122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist