Healthcare Provider Details

I. General information

NPI: 1144395161
Provider Name (Legal Business Name): JAMES P HEYNEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 N ELIDA ST
WINNEBAGO IL
61088
US

IV. Provider business mailing address

PO BOX 187 502 N ELIDA ST
WINNEBAGO IL
61088
US

V. Phone/Fax

Practice location:
  • Phone: 815-335-7368
  • Fax: 815-335-1618
Mailing address:
  • Phone: 815-335-7368
  • Fax: 815-335-1618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number19014475
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: