Healthcare Provider Details

I. General information

NPI: 1457774184
Provider Name (Legal Business Name): NATALIE RUTH HEAIVILIN D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2014
Last Update Date: 11/09/2021
Certification Date: 11/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 N UNIVERSITY AVE
ANN ARBOR MI
48109-1078
US

IV. Provider business mailing address

3515 LARCHMONT DR
ANN ARBOR MI
48105-2853
US

V. Phone/Fax

Practice location:
  • Phone: 734-936-5950
  • Fax:
Mailing address:
  • Phone: 913-593-5842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number0401416320
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number63326
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901601122
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: