Provider Demographics
NPI:1275580334
Name:HALUB, KEVIN M (DDS)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:HALUB
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 1:1615 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:MI
Mailing Address - Zip Code:49304-7984
Mailing Address - Country:US
Mailing Address - Phone:231-745-2736
Mailing Address - Fax:231-745-0412
Practice Address - Street 1:1035 E WILCOX AVE
Practice Address - Street 2:
Practice Address - City:WHITE CLOUD
Practice Address - State:MI
Practice Address - Zip Code:49349-8794
Practice Address - Country:US
Practice Address - Phone:231-689-1608
Practice Address - Fax:231-689-3162
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010140011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4718084Medicaid
MID800473OtherBLUE CROSS BLUE SHEILD