Healthcare Provider Details

I. General information

NPI: 1609950740
Provider Name (Legal Business Name): LESLIE B HEFFEZ DMD, MS, FRCD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 12/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1893 SHERIDAN RD #311
HIGHLAND PARK IL
60035-2628
US

IV. Provider business mailing address

1893 SHERIDAN RD #311
HIGHLAND PARK IL
60035-2628
US

V. Phone/Fax

Practice location:
  • Phone: 847-433-6636
  • Fax: 847-433-2090
Mailing address:
  • Phone: 847-433-6636
  • Fax: 847-433-2090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number190-18500
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: