Provider Demographics
NPI:1942452545
Name:BRIAN HALLER DMD LLC
Entity Type:Organization
Organization Name:BRIAN HALLER DMD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HALLER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:573-364-7969
Mailing Address - Street 1:PO BOX 393
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65402-0393
Mailing Address - Country:US
Mailing Address - Phone:573-364-7969
Mailing Address - Fax:
Practice Address - Street 1:602 W 6TH ST
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2941
Practice Address - Country:US
Practice Address - Phone:573-364-7969
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-15
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0138421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty