Provider Demographics
NPI:1992870927
Name:HALE, LAURA L (DDS)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:L
Last Name:HALE
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 1:608 LA JOYA ST STE B
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-3467
Mailing Address - Country:US
Mailing Address - Phone:505-753-9454
Mailing Address - Fax:
Practice Address - Street 1:9605 GRAND RONDE RD
Practice Address - Street 2:
Practice Address - City:GRAND RONDE
Practice Address - State:OR
Practice Address - Zip Code:97347-9712
Practice Address - Country:US
Practice Address - Phone:503-879-2020
Practice Address - Fax:503-879-2071
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD11922122300000X
NMDD3192122300000X
IA08516122300000X
NE66481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025408800Medicaid
IA0723403Medicaid
NE1883524OtherUNITED CONCORDIA