Provider Demographics
NPI:1902273782
Name:HALEY, THEODORE BOOTH (DDS)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:BOOTH
Last Name:HALEY
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 1:298 GRAND AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610-4895
Mailing Address - Country:US
Mailing Address - Phone:206-313-3505
Mailing Address - Fax:
Practice Address - Street 1:298 GRAND AVE STE 200
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-4895
Practice Address - Country:US
Practice Address - Phone:510-452-1068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-27
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64807122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice