Provider Demographics
NPI:1295584092
Name:HALVERSEN, GEOFFREY THOMAS
Entity type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:THOMAS
Last Name:HALVERSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250-2511
Mailing Address - Country:US
Mailing Address - Phone:812-599-5295
Mailing Address - Fax:
Practice Address - Street 1:5 ALLIED DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72202-2013
Practice Address - Country:US
Practice Address - Phone:501-437-8911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-14
Last Update Date:2025-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4799122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist