Healthcare Provider Details

I. General information

NPI: 1760403521
Provider Name (Legal Business Name): JEFFREY P. HALVORSON D.D.S, M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4355 SAWKAW DR NE
GRAND RAPIDS MI
49525-1768
US

IV. Provider business mailing address

4355 SAWKAW DR NE
GRAND RAPIDS MI
49525-1768
US

V. Phone/Fax

Practice location:
  • Phone: 616-361-6609
  • Fax: 616-361-6248
Mailing address:
  • Phone: 616-361-6609
  • Fax: 616-361-6248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number13465
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: