Healthcare Provider Details

I. General information

NPI: 1417001835
Provider Name (Legal Business Name): USS DWIGHT D EISENHOWER CVN 69
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USS DWIGHT EISENHOWER, DENTAL
FPO AE
09532
US

IV. Provider business mailing address

USS DWIGHT EISENHOWER, DENTAL
FPO AE
09532
US

V. Phone/Fax

Practice location:
  • Phone: 757-445-3302
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number30020312
License Number StateOH

VIII. Authorized Official

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