Provider Demographics
NPI:1134295660
Name:HERITAGE DENTAL CENTERS, P.A.
Entity Type:Organization
Organization Name:HERITAGE DENTAL CENTERS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILCOX
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-537-6070
Mailing Address - Street 1:8500 42ND AVE N
Mailing Address - Street 2:
Mailing Address - City:NEW HOPE
Mailing Address - State:MN
Mailing Address - Zip Code:55427
Mailing Address - Country:US
Mailing Address - Phone:763-537-6070
Mailing Address - Fax:763-537-6076
Practice Address - Street 1:8500 42ND AVE N
Practice Address - Street 2:
Practice Address - City:NEW HOPE
Practice Address - State:MN
Practice Address - Zip Code:55427
Practice Address - Country:US
Practice Address - Phone:763-537-6070
Practice Address - Fax:763-537-6076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center