Provider Demographics
NPI:1619051968
Name:HALTOM, GEORGE WAYNE III (DDS)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:WAYNE
Last Name:HALTOM
Suffix:III
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 1:406 S HYLAND PARK DRIVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:GLENWOOD SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81601-4274
Mailing Address - Country:US
Mailing Address - Phone:970-945-9644
Mailing Address - Fax:970-945-0760
Practice Address - Street 1:406 S HYLAND PARK DRIVE
Practice Address - Street 2:SUITE B
Practice Address - City:GLENWOOD SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81601-4274
Practice Address - Country:US
Practice Address - Phone:970-945-9644
Practice Address - Fax:970-945-0760
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COHD1044681223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO71865Medicare ID - Type Unspecified
COC71865Medicare UPIN