Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 3815 | ME |
NPI | 1003995192 |
---|---|
Provider Name | Brendan Hallissey |
First Address | Kittery, ME 03904 |
Second Address | Kittery, ME 03904 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/11/2006 |
Last Update Date | 17/10/2013 |