=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831297787
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES HALTERMAN DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 840 MAIN ST
-----------------------------------------------------
City | HALF MOON BAY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94019-2187
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-726-6884
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 185 REEF POINT RD
-----------------------------------------------------
City | MOSS BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94038-9779
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-728-3877
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 21579
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------