Provider Demographics
NPI:1083719223
Name:HALBERSTADT, GEOFFREY STUART
Entity Type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:STUART
Last Name:HALBERSTADT
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 1:86 VOORHIS AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-2746
Mailing Address - Country:US
Mailing Address - Phone:516-729-7736
Mailing Address - Fax:516-678-0289
Practice Address - Street 1:20 CONTINENTAL AVENUE
Practice Address - Street 2:SUITE 1 G
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-5266
Practice Address - Country:US
Practice Address - Phone:718-261-1400
Practice Address - Fax:718-261-1401
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0325131223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1083719223Medicaid
NY01203763Medicaid