Provider Demographics
NPI:1891771960
Name:VAN HEUKELOM, JOHN R (DDS MS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:VAN HEUKELOM
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 3RD AVE SE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52403-2407
Mailing Address - Country:US
Mailing Address - Phone:319-365-8441
Mailing Address - Fax:319-365-0480
Practice Address - Street 1:835 3RD AVE SE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52403-2407
Practice Address - Country:US
Practice Address - Phone:319-365-8441
Practice Address - Fax:319-365-0480
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA062391223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0181933Medicaid
IAT01048Medicare UPIN
IA47403Medicare ID - Type Unspecified