Provider Demographics
NPI:1487612057
Name:IVERSEN, WILLIAM WALTER (DDS MS)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:WALTER
Last Name:IVERSEN
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 S SHIELDS
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80521
Mailing Address - Country:US
Mailing Address - Phone:970-484-3214
Mailing Address - Fax:970-484-4007
Practice Address - Street 1:1103 S SHIELDS
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80521
Practice Address - Country:US
Practice Address - Phone:970-484-3214
Practice Address - Fax:970-484-4007
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1047351223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO87457563Medicaid