Provider Demographics
NPI:1356490700
Name:HERITAGE DENTAL
Entity Type:Organization
Organization Name:HERITAGE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER OF CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:JAZDZEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-395-1461
Mailing Address - Street 1:800 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:IL
Mailing Address - Zip Code:60002-1542
Mailing Address - Country:US
Mailing Address - Phone:847-395-1461
Mailing Address - Fax:847-395-9255
Practice Address - Street 1:800 MAIN ST
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:IL
Practice Address - Zip Code:60002-1542
Practice Address - Country:US
Practice Address - Phone:847-395-1461
Practice Address - Fax:847-395-9255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty