Provider Demographics
NPI:1306157946
Name:HEIDENREICH, DAVID JOHN (DDS)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JOHN
Last Name:HEIDENREICH
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 1:1225 S CHURCH ST
Mailing Address - Street 2:APT 126
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-4017
Mailing Address - Country:US
Mailing Address - Phone:402-659-9729
Mailing Address - Fax:
Practice Address - Street 1:7868 REA RD STE B
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-6548
Practice Address - Country:US
Practice Address - Phone:402-659-9729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-29
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010018671122300000X
SC6950122300000X
NC9091122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist