Provider Demographics
NPI:1144891482
Name:GENOA, HAYLIE PRISCILLA
Entity type:Individual
Prefix:
First Name:HAYLIE
Middle Name:PRISCILLA
Last Name:GENOA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORTER
Mailing Address - State:ME
Mailing Address - Zip Code:04068-3527
Mailing Address - Country:US
Mailing Address - Phone:207-625-8126
Mailing Address - Fax:207-625-7820
Practice Address - Street 1:70 MAIN ST
Practice Address - Street 2:
Practice Address - City:PORTER
Practice Address - State:ME
Practice Address - Zip Code:04068-3527
Practice Address - Country:US
Practice Address - Phone:207-625-2267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-07
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDEN4901122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist