Provider Demographics
NPI:1033438957
Name:HERITAGE CREEK DENTAL LLC
Entity Type:Organization
Organization Name:HERITAGE CREEK DENTAL LLC
Other - Org Name:HERITAGE CREEK DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLINTON
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:TIMMERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:515-783-7129
Mailing Address - Street 1:11088 HICKMAN RD
Mailing Address - Street 2:
Mailing Address - City:CLIVE
Mailing Address - State:IA
Mailing Address - Zip Code:50325-3740
Mailing Address - Country:US
Mailing Address - Phone:515-278-2253
Mailing Address - Fax:515-278-2392
Practice Address - Street 1:11088 HICKMAN RD
Practice Address - Street 2:
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-3740
Practice Address - Country:US
Practice Address - Phone:515-278-2253
Practice Address - Fax:515-278-2392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-18
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA08515122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty