Provider Demographics
NPI:1780781658
Name:HEIDELBERG, DAVID RAYMOND (DDS)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:RAYMOND
Last Name:HEIDELBERG
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 1:4 VICTORIA CIR
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:OH
Mailing Address - Zip Code:44857-1656
Mailing Address - Country:US
Mailing Address - Phone:419-663-7515
Mailing Address - Fax:
Practice Address - Street 1:30 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:OH
Practice Address - Zip Code:44857-2480
Practice Address - Country:US
Practice Address - Phone:419-668-6589
Practice Address - Fax:419-663-4601
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH177941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0633747Medicaid