Provider Demographics
NPI:1174676217
Name:HALLSTROM, KEVIN R (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:R
Last Name:HALLSTROM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 BECKER AVE SW
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-3232
Mailing Address - Country:US
Mailing Address - Phone:320-235-2551
Mailing Address - Fax:320-235-0549
Practice Address - Street 1:512 BECKER AVE SW
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-3232
Practice Address - Country:US
Practice Address - Phone:320-235-2551
Practice Address - Fax:320-235-0549
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN90691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice