Provider Demographics
NPI:1720148059
Name:HEIDERMAN, RONALD A (DDS)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:A
Last Name:HEIDERMAN
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 1:4806 N HAMILTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-1406
Mailing Address - Country:US
Mailing Address - Phone:773-561-0455
Mailing Address - Fax:773-561-0455
Practice Address - Street 1:4806 N HAMILTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-1406
Practice Address - Country:US
Practice Address - Phone:773-561-0455
Practice Address - Fax:773-561-0455
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.018262122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist