Provider Demographics
NPI:1083786909
Name:HEBERER, DWIGHT DAVID (DMD)
Entity Type:Individual
Prefix:DR
First Name:DWIGHT
Middle Name:DAVID
Last Name:HEBERER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 BASS LN
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-7626
Mailing Address - Country:US
Mailing Address - Phone:618-476-7038
Mailing Address - Fax:
Practice Address - Street 1:226 WESTVIEW PLAZA DR.
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298-2123
Practice Address - Country:US
Practice Address - Phone:618-939-4042
Practice Address - Fax:618-939-5404
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190203201223G0001X, 332B00000X, 332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No1223G0001XDental ProvidersDentistGeneral Practice
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies