Provider Demographics
NPI:1063645703
Name:HEREDIA, DAVID (ORAL SURGERY ASST)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:HEREDIA
Suffix:
Gender:M
Credentials:ORAL SURGERY ASST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1432 N G ST APT 4
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92405-4342
Mailing Address - Country:US
Mailing Address - Phone:909-663-7331
Mailing Address - Fax:
Practice Address - Street 1:1432 N G ST APT 4
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92405-4342
Practice Address - Country:US
Practice Address - Phone:909-663-7331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-28
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant