Provider Demographics
NPI:1558356311
Name:HALTOM, KATHERINE ANNE (DMD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ANNE
Last Name:HALTOM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 WALNUT ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:FRAMINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01702-7500
Mailing Address - Country:US
Mailing Address - Phone:508-879-8004
Mailing Address - Fax:508-879-6327
Practice Address - Street 1:223 WALNUT ST
Practice Address - Street 2:SUITE 2
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01702-7500
Practice Address - Country:US
Practice Address - Phone:508-879-8004
Practice Address - Fax:508-879-6327
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-16
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA143721223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
T57251Medicare UPIN
MAX04431Medicare ID - Type Unspecified