MEDICARE: DELAWARE DENTAL PARTNERS, LLP.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	22117	OH

General Provider Information

NPI Number	:	1649506551
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DELAWARE DENTAL PARTNERS, LLP.

Provider Business Mailing Address
First Line	:	1179 COLUMBUS PIKE
Second Line	:
City	:	DELAWARE
State	:	OH
Zip	:	43015-2713
Country	:	US
Telephone Number	:	740-362-2202
Fax Number	:	740-362-2204

Provider Business Practice Location Address
First Line	:	1179 COLUMBUS PIKE
Second Line	:
City	:	DELAWARE
State	:	OH
Zip	:	43015-2713
Country	:	US
Telephone Number	:	740-362-2202
Fax Number	:	740-362-2204

Authorized Official
Title or Position	:	DDS
Name	:	DR. MARK HALVERSEN
Credential	:
Telephone Number	:	740-362-2202

Provider Enumeration Date	:	10/28/2009
Last Update Date	:	10/28/2009

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