Provider Demographics
NPI:1609424837
Name:MATEJKA, HEATHER NICOLE (DMD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:NICOLE
Last Name:MATEJKA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3909 FARMINGTON LN
Mailing Address - Street 2:
Mailing Address - City:JOHNSBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60051-5175
Mailing Address - Country:US
Mailing Address - Phone:815-861-2354
Mailing Address - Fax:
Practice Address - Street 1:6226 14TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-4413
Practice Address - Country:US
Practice Address - Phone:815-861-2354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-30
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002180122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist