Provider Demographics
NPI:1104990902
Name:IVERSON, DANIEL WALTER (DDS)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:WALTER
Last Name:IVERSON
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 1:510 1ST AVE
Mailing Address - Street 2:P.O. BOX 59
Mailing Address - City:TWO HARBORS
Mailing Address - State:MN
Mailing Address - Zip Code:55616-1504
Mailing Address - Country:US
Mailing Address - Phone:218-834-2011
Mailing Address - Fax:218-834-6028
Practice Address - Street 1:510 1ST AVE
Practice Address - Street 2:
Practice Address - City:TWO HARBORS
Practice Address - State:MN
Practice Address - Zip Code:55616-1504
Practice Address - Country:US
Practice Address - Phone:218-834-2011
Practice Address - Fax:218-834-6028
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN85921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice