Provider Demographics
NPI:1609950740
Name:HEFFEZ, LESLIE B (DMD, MS, FRCD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:B
Last Name:HEFFEZ
Suffix:
Gender:M
Credentials:DMD, MS, FRCD
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Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1893 SHERIDAN RD
Mailing Address - Street 2:#311
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-2628
Mailing Address - Country:US
Mailing Address - Phone:847-433-6636
Mailing Address - Fax:847-433-2090
Practice Address - Street 1:1893 SHERIDAN RD
Practice Address - Street 2:#311
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-2628
Practice Address - Country:US
Practice Address - Phone:847-433-6636
Practice Address - Fax:847-433-2090
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2013-12-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL190-18500204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
T78436Medicare UPIN