Provider Demographics
NPI:1801586854
Name:DR DAVID R HEIDENREICH
Entity type:Organization
Organization Name:DR DAVID R HEIDENREICH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:HEIDENREICH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:269-781-7997
Mailing Address - Street 1:105 E GREEN ST
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068-1532
Mailing Address - Country:US
Mailing Address - Phone:269-781-7997
Mailing Address - Fax:
Practice Address - Street 1:105 E GREEN ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MI
Practice Address - Zip Code:49068-1532
Practice Address - Country:US
Practice Address - Phone:269-781-7997
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-12
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty