Provider Demographics
NPI:1538233218
Name:HALEY, WALTER S (DDS)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:S
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:PO BOX 621
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98507-0621
Mailing Address - Country:US
Mailing Address - Phone:360-352-0065
Mailing Address - Fax:360-352-6270
Practice Address - Street 1:925 TROSPER RD SW
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512-6937
Practice Address - Country:US
Practice Address - Phone:360-352-0065
Practice Address - Fax:360-352-6270
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00008563122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist