Healthcare Provider Details

I. General information

NPI: 1396738746
Provider Name (Legal Business Name): PETER J. HEATH D.D.S., M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 09/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 E DAY RD SUITE 260
MISHAWAKA IN
46545-3444
US

IV. Provider business mailing address

270 E DAY RD SUITE 260
MISHAWAKA IN
46545-3444
US

V. Phone/Fax

Practice location:
  • Phone: 574-272-8823
  • Fax: 574-277-1837
Mailing address:
  • Phone: 574-272-8823
  • Fax: 574-277-1837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number9545
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2503
License Number StateNH
# 3
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number12434R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: