Provider Demographics
NPI:1194087007
Name:HEEREN, JAY (DDS)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:
Last Name:HEEREN
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 1:866 LAZELLE ST
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:SD
Mailing Address - Zip Code:57785-1611
Mailing Address - Country:US
Mailing Address - Phone:605-347-8880
Mailing Address - Fax:605-347-2011
Practice Address - Street 1:866 LAZELLE ST
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:SD
Practice Address - Zip Code:57785-1611
Practice Address - Country:US
Practice Address - Phone:605-347-8880
Practice Address - Fax:605-347-2011
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-15
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDD0997122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist