Provider Demographics
NPI:1811300437
Name:HEITZLER, MICHAELLA RADICH (DMD)
Entity type:Individual
Prefix:DR
First Name:MICHAELLA
Middle Name:RADICH
Last Name:HEITZLER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:KETA
Other - Middle Name:
Other - Last Name:RADICH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1611 N. WOLCOTT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622
Mailing Address - Country:US
Mailing Address - Phone:312-281-4860
Mailing Address - Fax:
Practice Address - Street 1:1611 N. WOLCOTT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622
Practice Address - Country:US
Practice Address - Phone:312-281-4860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-11
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0297191223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry