Provider Demographics
NPI:1720820731
Name:HIBBARD, HAYLEY
Entity type:Individual
Prefix:
First Name:HAYLEY
Middle Name:
Last Name:HIBBARD
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 1:163 PLEASANT AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-3242
Mailing Address - Country:US
Mailing Address - Phone:207-773-3794
Mailing Address - Fax:
Practice Address - Street 1:163 PLEASANT AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-3242
Practice Address - Country:US
Practice Address - Phone:207-773-3794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDEN51511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice