Provider Demographics
NPI:1396738746
Name:HEATH, PETER J (DDS, MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:J
Last Name:HEATH
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 E DAY RD
Mailing Address - Street 2:SUITE 260
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-3444
Mailing Address - Country:US
Mailing Address - Phone:574-272-8823
Mailing Address - Fax:574-277-1837
Practice Address - Street 1:270 E DAY RD
Practice Address - Street 2:SUITE 260
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3444
Practice Address - Country:US
Practice Address - Phone:574-272-8823
Practice Address - Fax:574-277-1837
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD95451223S0112X
NH25031223S0112X
LA12434R204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01063978AOtherIN MEDICAL LICENSE
IN200870900Medicaid
NH2503OtherDENTAL LICENSE (INACTIVE)
MD9545OtherDENTAL LICENSE
IN12011044AOtherIN DENTAL LICENSE
LA12434ROtherMEDICAL LICENSE
IN252600AMedicare PIN