MEDICARE: HALVORSON & HEMBROUGH D.D.S, .M.S., PC

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	1223E0200X	Endodontics

General Provider Information

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

Provider Business Mailing Address
First Line	:	4355 SAWKAW DR NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-1768
Country	:	US
Telephone Number	:	616-361-6609
Fax Number	:	616-361-6248

Provider Business Practice Location Address
First Line	:	4355 SAWKAW DR NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-1768
Country	:	US
Telephone Number	:	616-361-6609
Fax Number	:	616-361-6248

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MS. KATHERINE KLUNGLE
Credential	:
Telephone Number	:	616-361-6609

Provider Enumeration Date	:	07/16/2006
Last Update Date	:	10/05/2007

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