Provider Demographics
NPI:1437490612
Name:HALVERSON, HEIDI LYNN (RDH LAP BS)
Entity Type:Individual
Prefix:MS
First Name:HEIDI
Middle Name:LYNN
Last Name:HALVERSON
Suffix:
Gender:F
Credentials:RDH LAP BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 LENORE CT
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-4723
Mailing Address - Country:US
Mailing Address - Phone:406-550-4482
Mailing Address - Fax:
Practice Address - Street 1:1710 LENORE CT
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-4723
Practice Address - Country:US
Practice Address - Phone:406-550-4482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-12
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTDEN-RDH-LIC-457124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTDEN-RDH-LIC-457OtherRDH