Healthcare Provider Details

I. General information

NPI: 1083786909
Provider Name (Legal Business Name): DWIGHT DAVID HEBERER D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 11/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 WESTVIEW PLAZA DR.
WATERLOO IL
62298-2123
US

IV. Provider business mailing address

16 BASS LN
BELLEVILLE IL
62223-7626
US

V. Phone/Fax

Practice location:
  • Phone: 618-939-4042
  • Fax: 618-939-5404
Mailing address:
  • Phone: 618-476-7038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019020320
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number019020320
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number019020320
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: