Provider Demographics
NPI:1538251939
Name:WATERFORD DENTIST PLLC
Entity type:Organization
Organization Name:WATERFORD DENTIST PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KURT
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:HEUERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-674-0495
Mailing Address - Street 1:4450 WALTON BLVD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329
Mailing Address - Country:US
Mailing Address - Phone:248-674-0495
Mailing Address - Fax:248-674-4308
Practice Address - Street 1:4450 W WALTON BLVD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48329-4093
Practice Address - Country:US
Practice Address - Phone:248-674-0495
Practice Address - Fax:248-674-4308
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEUERMAN SHUMAKER PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-29
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty