Provider Demographics
NPI:1770145716
Name:GULLEY, HALIE FAYE (DDS)
Entity type:Individual
Prefix:
First Name:HALIE
Middle Name:FAYE
Last Name:GULLEY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:HALIE
Other - Middle Name:FAYE
Other - Last Name:MOITOZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:3009 HWY K
Mailing Address - Street 2:
Mailing Address - City:O'FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368
Mailing Address - Country:US
Mailing Address - Phone:636-379-7552
Mailing Address - Fax:636-379-7553
Practice Address - Street 1:3009 HWY K
Practice Address - Street 2:
Practice Address - City:O'FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368
Practice Address - Country:US
Practice Address - Phone:636-379-7552
Practice Address - Fax:636-379-7553
Is Sole Proprietor?:No
Enumeration Date:2019-06-29
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20190461791223G0001X
KS61666122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice