Provider Demographics
NPI:1518137652
Name:HEYDARI, ELLIE (DDS)
Entity Type:Individual
Prefix:
First Name:ELLIE
Middle Name:
Last Name:HEYDARI
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 1:36745 AIKEN RD
Mailing Address - Street 2:36745 AIKEN RD.
Mailing Address - City:BAYFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54814-4579
Mailing Address - Country:US
Mailing Address - Phone:715-779-3707
Mailing Address - Fax:715-779-3622
Practice Address - Street 1:36745 AIKEN RD.
Practice Address - Street 2:RED CLIFF COMMUNITY HEALTH CENTER
Practice Address - City:BAYFIELD
Practice Address - State:WI
Practice Address - Zip Code:54814
Practice Address - Country:US
Practice Address - Phone:715-779-3707
Practice Address - Fax:715-779-3622
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-05
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010174681223G0001X
WI7252-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice