Provider Demographics
NPI:1013185883
Name:HALSTROM, RANDY MICHAEL
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:MICHAEL
Last Name:HALSTROM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4572 PINE POINT RD
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-9748
Mailing Address - Country:US
Mailing Address - Phone:320-367-0389
Mailing Address - Fax:
Practice Address - Street 1:4572 PINE POINT RD
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-9748
Practice Address - Country:US
Practice Address - Phone:320-367-0389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-14
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND7550122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist