Provider Demographics
NPI:1962881748
Name:LEGACY DENTAL OF GLEN OAKS
Entity type:Organization
Organization Name:LEGACY DENTAL OF GLEN OAKS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:GERALD
Authorized Official - Last Name:HEFFELFINGER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-563-8383
Mailing Address - Street 1:4767 VISTA WOOD BLVD
Mailing Address - Street 2:STE 110
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75232
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4767 VISTA WOOD BLVD
Practice Address - Street 2:STE 110
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75232
Practice Address - Country:US
Practice Address - Phone:214-321-8383
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-26
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX253931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty