Provider Demographics
NPI:1750501789
Name:HELLER, MICHAEL BENJAMIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BENJAMIN
Last Name:HELLER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:TOMKINS COVE
Mailing Address - State:NY
Mailing Address - Zip Code:10986-1615
Mailing Address - Country:US
Mailing Address - Phone:845-429-0363
Mailing Address - Fax:240-208-2176
Practice Address - Street 1:120 COUNTY RD
Practice Address - Street 2:
Practice Address - City:TENAFLY
Practice Address - State:NJ
Practice Address - Zip Code:07670-1854
Practice Address - Country:US
Practice Address - Phone:201-568-1190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJD040702001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0111287Medicaid