Provider Demographics
NPI:1801078464
Name:HEIDENRICH, JOHN R (DDS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:HEIDENRICH
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 1:480 ALTA RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92179-0001
Mailing Address - Country:US
Mailing Address - Phone:619-661-6500
Mailing Address - Fax:
Practice Address - Street 1:480 ALTA RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92179-0001
Practice Address - Country:US
Practice Address - Phone:619-661-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-05
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25148122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist