Provider Demographics
NPI:1447417118
Name:HEARTLAND HEALTH OUTREACH
Entity Type:Organization
Organization Name:HEARTLAND HEALTH OUTREACH
Other - Org Name:SPANG DENTAL CENTER WEST
Other - Org Type:Other Name
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-751-4107
Mailing Address - Street 1:4750 N SHERIDAN RD
Mailing Address - Street 2:SUITE 434
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-7528
Mailing Address - Country:US
Mailing Address - Phone:773-751-1704
Mailing Address - Fax:773-751-4175
Practice Address - Street 1:2418 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-2940
Practice Address - Country:US
Practice Address - Phone:773-252-6413
Practice Address - Fax:773-252-6417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL103326OtherDORAL DENTAL
IL017Medicaid