Provider Demographics
NPI:1366586208
Name:HALLAIAN, KEITH (DMD, MD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:
Last Name:HALLAIAN
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-3520
Mailing Address - Country:US
Mailing Address - Phone:631-265-6533
Mailing Address - Fax:631-265-6723
Practice Address - Street 1:80 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3520
Practice Address - Country:US
Practice Address - Phone:631-265-6533
Practice Address - Fax:631-265-6723
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0482481223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02325744Medicaid
NYV00767Medicare ID - Type Unspecified