Provider Demographics
NPI:1699323576
Name:HALLER, CHARITY KEONNA (DMD)
Entity type:Individual
Prefix:DR
First Name:CHARITY
Middle Name:KEONNA
Last Name:HALLER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 HITREE LN
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14624-4740
Mailing Address - Country:US
Mailing Address - Phone:716-860-6822
Mailing Address - Fax:
Practice Address - Street 1:310 CONTINENTAL DRIVE
Practice Address - Street 2:SUTIE 106
Practice Address - City:JAL
Practice Address - State:NM
Practice Address - Zip Code:88252-2525
Practice Address - Country:US
Practice Address - Phone:753-952-2095
Practice Address - Fax:575-395-2205
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-03
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NYDB-2024-00581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty