Healthcare Provider Details

I. General information

NPI: 1063453603
Provider Name (Legal Business Name): EVAN STUART HALPERN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1727 N RIVERSIDE AVE
RIALTO CA
92376-8062
US

IV. Provider business mailing address

5553 MIDDLEBURY CT
ETIWANDA CA
91739-8916
US

V. Phone/Fax

Practice location:
  • Phone: 909-820-9413
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number44407
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: