MEDICARE: USS DWIGHT D EISENHOWER CVN 69

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	30020312	OH

General Provider Information

NPI Number	:	1417001835
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	USS DWIGHT D EISENHOWER CVN 69

Provider Business Mailing Address
First Line	:	USS DWIGHT EISENHOWER, DENTAL
Second Line	:
City	:	FPO
State	:	AE
Zip	:	09532
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	USS DWIGHT EISENHOWER, DENTAL
Second Line	:
City	:	FPO
State	:	AE
Zip	:	09532
Country	:	US
Telephone Number	:	757-445-3302
Fax Number	:

Authorized Official
Title or Position	:	ORAL & MAXILLOFACIAL SURGEON
Name	:	DR. SANDRA M HALTERMAN
Credential	:	D.M.D.
Telephone Number	:	747-445-3302

Provider Enumeration Date	:	01/23/2007
Last Update Date	:	08/22/2020

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