Provider Demographics
NPI:1811073968
Name:HALVERSON, BRADLEY ALAN (DMD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:ALAN
Last Name:HALVERSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1933 S CHEKSHANI CLF
Mailing Address - Street 2:
Mailing Address - City:NEW HARMONY
Mailing Address - State:UT
Mailing Address - Zip Code:84757-5136
Mailing Address - Country:US
Mailing Address - Phone:435-867-6190
Mailing Address - Fax:
Practice Address - Street 1:1933 S CHEKSHANI CLF
Practice Address - Street 2:
Practice Address - City:NEW HARMONY
Practice Address - State:UT
Practice Address - Zip Code:84757-5136
Practice Address - Country:US
Practice Address - Phone:435-867-6190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3100748-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist