Provider Demographics
NPI:1144395161
Name:HEYNEN, JAMES P (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:P
Last Name:HEYNEN
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:PO BOX 187
Mailing Address - Street 2:502 N ELIDA ST
Mailing Address - City:WINNEBAGO
Mailing Address - State:IL
Mailing Address - Zip Code:61088
Mailing Address - Country:US
Mailing Address - Phone:815-335-7368
Mailing Address - Fax:815-335-1618
Practice Address - Street 1:502 N ELIDA ST
Practice Address - Street 2:
Practice Address - City:WINNEBAGO
Practice Address - State:IL
Practice Address - Zip Code:61088
Practice Address - Country:US
Practice Address - Phone:815-335-7368
Practice Address - Fax:815-335-1618
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19014475122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist