Provider Demographics
NPI:1194044842
Name:HALBERG, DEVON (DDS)
Entity type:Individual
Prefix:
First Name:DEVON
Middle Name:
Last Name:HALBERG
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 1:1632 WASHINGTON ST NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-1336
Mailing Address - Country:US
Mailing Address - Phone:612-789-2853
Mailing Address - Fax:612-767-3490
Practice Address - Street 1:1632 WASHINGTON ST NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-1336
Practice Address - Country:US
Practice Address - Phone:612-789-2853
Practice Address - Fax:612-767-3490
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-20
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12783122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist