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General NPI Number Information
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NPI Number | 1295266476
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Entity Type | Individual
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Provider Name | ANDREW HALVERSON MDT
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Gender | Male
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Dates
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Enumeration Date | 03/21/2017
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Last Update Date | 03/21/2017
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Provider Practice Location Address
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Address Line | 450 SYNDICATE ST N #300
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City | SAINT PAUL
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State | MN
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Zip | 55104-4107
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Country | US
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Telephone | 651-254-7374
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Fax |
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Provider Business Mailing Address
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Address Line | 2651 INNSBRUCK CT
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City | NEW BRIGHTON
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State | MN
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Zip | 55112-6364
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 125J00000X
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Taxonomy Name | Dental Therapist
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License Number | 82
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License Number State | MN
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