Provider Demographics
NPI:1164596540
Name:HALLECK, BRAD N (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:N
Last Name:HALLECK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-3829
Mailing Address - Country:US
Mailing Address - Phone:360-423-7020
Mailing Address - Fax:360-423-5325
Practice Address - Street 1:307 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BATTLE GROUND
Practice Address - State:WA
Practice Address - Zip Code:98604-4411
Practice Address - Country:US
Practice Address - Phone:360-666-0100
Practice Address - Fax:360-841-7070
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000085041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice