Provider Demographics
NPI:1063048742
Name:HALLIBURTON FAMILY DENTISTRY
Entity type:Organization
Organization Name:HALLIBURTON FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:VIVIAN
Authorized Official - Last Name:HALLIBURTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:917-687-0722
Mailing Address - Street 1:9218 MAGGIES WAY
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20723-1376
Mailing Address - Country:US
Mailing Address - Phone:917-687-0722
Mailing Address - Fax:443-545-5299
Practice Address - Street 1:5096 DORSEY HALL DR STE 106
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-7711
Practice Address - Country:US
Practice Address - Phone:917-687-0722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-13
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty