Provider Demographics
NPI:1083826507
Name:HERRON, DEVERE J (DDS)
Entity Type:Individual
Prefix:DR
First Name:DEVERE
Middle Name:J
Last Name:HERRON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7203 SOUTH WESTERN AVENUE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60636
Mailing Address - Country:US
Mailing Address - Phone:773-476-5335
Mailing Address - Fax:773-476-4353
Practice Address - Street 1:7203 SOUTH WESTERN AVENUE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60636
Practice Address - Country:US
Practice Address - Phone:773-476-5335
Practice Address - Fax:773-476-4353
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019022784122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019022784OtherSTATE LICENSE