Healthcare Provider Details

I. General information

NPI: 1386633295
Provider Name (Legal Business Name): HEATHER SURRATT D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 BOND AVE SIHF - MCC
CENTREVILLE IL
62207-2328
US

IV. Provider business mailing address

1160 TAZEWELL DR
O FALLON IL
62269-7149
US

V. Phone/Fax

Practice location:
  • Phone: 618-332-2740
  • Fax: 618-332-8755
Mailing address:
  • Phone: 618-632-5090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number19-026518
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: