Provider Demographics
NPI:1609907757
Name:HALVORSEN, LAURA L
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:L
Last Name:HALVORSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:MORAGA
Mailing Address - State:CA
Mailing Address - Zip Code:94556-1924
Mailing Address - Country:US
Mailing Address - Phone:925-376-4626
Mailing Address - Fax:
Practice Address - Street 1:1004 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:MORAGA
Practice Address - State:CA
Practice Address - Zip Code:94556-1924
Practice Address - Country:US
Practice Address - Phone:925-376-4626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA468161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice