Provider Demographics
NPI:1336271402
Name:HALVERSEN, MARK STAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:STAN
Last Name:HALVERSEN
Suffix:
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 1:1179 COLUMBUS PIKE
Mailing Address - Street 2:STATE ROUTE 23
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015-2713
Mailing Address - Country:US
Mailing Address - Phone:740-362-2202
Mailing Address - Fax:740-362-2204
Practice Address - Street 1:1179 COLUMBUS PIKE
Practice Address - Street 2:STATE ROUTE 23
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-2713
Practice Address - Country:US
Practice Address - Phone:740-362-2202
Practice Address - Fax:740-362-2204
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH22117122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist