Healthcare Provider Details

I. General information

NPI: 1861419640
Provider Name (Legal Business Name): HALVORSON & HEMBROUGH D.D.S, .M.S., PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 10/05/2007
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 Number
License Number State

VIII. Authorized Official

Name: MS. KATHERINE KLUNGLE
Title or Position: OFFICE MANAGER
Credential:
Phone: 616-361-6609