Provider Demographics
NPI:1821665001
Name:PETZEL, HEIDI (DDS)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:PETZEL
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 1:9630 GROVE CIR N STE 102
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-3480
Mailing Address - Country:US
Mailing Address - Phone:763-420-5484
Mailing Address - Fax:
Practice Address - Street 1:9630 GROVE CIR N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-3464
Practice Address - Country:US
Practice Address - Phone:763-420-5484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-07
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND14559122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist