Provider Demographics
NPI:1386633295
Name:SURRATT, HEATHER (DDS)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:
Last Name:SURRATT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 TAZEWELL DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-7149
Mailing Address - Country:US
Mailing Address - Phone:618-632-5090
Mailing Address - Fax:
Practice Address - Street 1:6000 BOND AVE
Practice Address - Street 2:SIHF - MCC
Practice Address - City:CENTREVILLE
Practice Address - State:IL
Practice Address - Zip Code:62207-2328
Practice Address - Country:US
Practice Address - Phone:618-332-2740
Practice Address - Fax:618-332-8755
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19-0265181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice