Healthcare Provider Details

I. General information

NPI: 1699753608
Provider Name (Legal Business Name): ERICH PHELPS HEITMAN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG 38717, 38TH STREET USA DENTAC
FT GORDON GA
30905-5660
US

IV. Provider business mailing address

BLDG 38717, 38TH STREET USA DENTAC
FT GORDON GA
30905-5660
US

V. Phone/Fax

Practice location:
  • Phone: 706-787-6927
  • Fax: 706-787-2082
Mailing address:
  • Phone: 706-787-6927
  • Fax: 706-787-2082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401410333
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: