Provider Demographics
NPI:1902029366
Name:HALLE, ROBERT IRA (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:IRA
Last Name:HALLE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:652 SUFFOLK AVE
Mailing Address - Street 2:SUITE #102
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717
Mailing Address - Country:US
Mailing Address - Phone:631-673-8060
Mailing Address - Fax:631-273-5255
Practice Address - Street 1:652 SUFFOLK AVE
Practice Address - Street 2:SUITE #102
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717
Practice Address - Country:US
Practice Address - Phone:631-673-8060
Practice Address - Fax:631-273-5255
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0416831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA38006OtherCALIFORNIA DENTAL LICENSE