Healthcare Provider Details

I. General information

NPI: 1447400791
Provider Name (Legal Business Name): DR JOHN F BLATTNER & DR DWIGHT D HEBERER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2008
Last Update Date: 11/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 WESTVIEW PLAZA DR
WATERLOO IL
62298-1253
US

IV. Provider business mailing address

226 WESTVIEW PLAZA DR
WATERLOO IL
62298-1253
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019016532
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number019016532
License Number StateIL

VIII. Authorized Official

Name: DR. JOHN F. BLATTNER
Title or Position: PARTNER
Credential: DDS
Phone: 618-337-4300