Provider Demographics
NPI:1902846827
Name:HEIDENREICH, JAMES G (DDS)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:G
Last Name:HEIDENREICH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6670 S DIVISION
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49548-7834
Mailing Address - Country:US
Mailing Address - Phone:616-455-7370
Mailing Address - Fax:616-455-2937
Practice Address - Street 1:6670 S DIVISION
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49548-7834
Practice Address - Country:US
Practice Address - Phone:616-455-7370
Practice Address - Fax:616-455-2937
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7854122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist