Healthcare Provider Details

I. General information

NPI: 1598970014
Provider Name (Legal Business Name): MYLES F HEFFERNAN JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 10/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 MAIN ST
SOUTH LANCASTER MA
01561
US

IV. Provider business mailing address

PO BOX 606
SOUTH LANCASTER MA
01561
US

V. Phone/Fax

Practice location:
  • Phone: 978-365-5643
  • Fax: 978-368-0145
Mailing address:
  • Phone: 978-365-5643
  • Fax: 978-368-0145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN17036
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: