Provider Demographics
NPI:1104925775
Name:TLC DENTAL OF WALLED LAKE, PLLC
Entity type:Organization
Organization Name:TLC DENTAL OF WALLED LAKE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KURT
Authorized Official - Middle Name:
Authorized Official - Last Name:HEUERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-624-4774
Mailing Address - Street 1:1264 S COMMERCE RD
Mailing Address - Street 2:
Mailing Address - City:WALLED LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48390-3008
Mailing Address - Country:US
Mailing Address - Phone:248-624-4774
Mailing Address - Fax:248-624-9256
Practice Address - Street 1:1264 S COMMERCE RD
Practice Address - Street 2:
Practice Address - City:WALLED LAKE
Practice Address - State:MI
Practice Address - Zip Code:48390-3008
Practice Address - Country:US
Practice Address - Phone:248-624-4774
Practice Address - Fax:248-624-9256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI180991223G0001X
MI29010187461223G0001X
MI172141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI17087OtherDDS