Provider Demographics
NPI:1164098802
Name:HEIDEMAN, JASON IRA (DDS)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:IRA
Last Name:HEIDEMAN
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 1:4020 N HILLS DR APT 39
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-2447
Mailing Address - Country:US
Mailing Address - Phone:732-947-8445
Mailing Address - Fax:
Practice Address - Street 1:6268 NORTH UNIVERSITY DRIVE
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321
Practice Address - Country:US
Practice Address - Phone:732-947-8445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-02
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLDN269921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program