Provider Demographics
NPI:1972325306
Name:ACKEILIA HEATRICE DDS PC
Entity type:Organization
Organization Name:ACKEILIA HEATRICE DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ACKEILIA
Authorized Official - Middle Name:K
Authorized Official - Last Name:HEATRICE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:636-333-9711
Mailing Address - Street 1:24 KIEFER CREEK ROAD
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63021-6013
Mailing Address - Country:US
Mailing Address - Phone:636-333-9711
Mailing Address - Fax:
Practice Address - Street 1:24 KIEFER CREEK ROAD
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MO
Practice Address - Zip Code:63021-6013
Practice Address - Country:US
Practice Address - Phone:636-333-9711
Practice Address - Fax:636-218-1891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-28
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO400092761Medicaid