Provider Demographics
NPI:1467982728
Name:HERITAGE DENTAL LLC
Entity Type:Organization
Organization Name:HERITAGE DENTAL LLC
Other - Org Name:HERITAGE DENTAL LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:BREAULT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:860-573-5681
Mailing Address - Street 1:9598 PALMETTO COMMERCE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9598 PALMETTO COMMERCE PARKWAY
Practice Address - Street 2:
Practice Address - City:LADSON
Practice Address - State:SC
Practice Address - Zip Code:29456
Practice Address - Country:US
Practice Address - Phone:860-573-5681
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-19
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8323261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC=========Other1223G0001X