Provider Demographics
NPI:1295465565
Name:AREVALO, HEINERY (DMD)
Entity Type:Individual
Prefix:
First Name:HEINERY
Middle Name:
Last Name:AREVALO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 S CLINTON ST APT 409A
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-3809
Mailing Address - Country:US
Mailing Address - Phone:630-656-2659
Mailing Address - Fax:
Practice Address - Street 1:6100 WASHINGTON AVE STE F2
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-4000
Practice Address - Country:US
Practice Address - Phone:262-999-9998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-10
Last Update Date:2023-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0336831223G0001X
WI6001069-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100216253Medicaid