Provider Demographics
NPI:1407831746
Name:HALLORAN, CAROL (DDS)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:HALLORAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 PLYMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-3524
Mailing Address - Country:US
Mailing Address - Phone:319-230-4554
Mailing Address - Fax:319-291-4077
Practice Address - Street 1:1950 PLYMOUTH AVE
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702-3524
Practice Address - Country:US
Practice Address - Phone:319-291-3908
Practice Address - Fax:319-291-4077
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-09
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA07465122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0076372Medicaid