Provider Demographics
NPI:1740501337
Name:HALVERSON, KELLY COMERFORD (DDS)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:COMERFORD
Last Name:HALVERSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 BUCKINGHAM RD
Mailing Address - Street 2:#104
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75081
Mailing Address - Country:US
Mailing Address - Phone:972-238-9626
Mailing Address - Fax:
Practice Address - Street 1:1001 BUCKINGHAM RD
Practice Address - Street 2:#104
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75081
Practice Address - Country:US
Practice Address - Phone:972-238-9626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-17
Last Update Date:2018-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25105122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist