Provider Demographics
NPI:1013081868
Name:HEISSER, BERT L (DDS)
Entity Type:Individual
Prefix:
First Name:BERT
Middle Name:L
Last Name:HEISSER
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 1:947 HALLOCK YOUNG RD SW
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44481-9636
Mailing Address - Country:US
Mailing Address - Phone:330-824-2515
Mailing Address - Fax:
Practice Address - Street 1:947 HALLOCK YOUNG RD SW
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44481-9636
Practice Address - Country:US
Practice Address - Phone:330-824-2515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH011820122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3812931Medicaid