Healthcare Provider Details

I. General information

NPI: 1467189183
Provider Name (Legal Business Name): HEINZ ORTHODONTICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2022
Last Update Date: 08/03/2022
Certification Date: 08/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

158 MARCELL DR NE STE A
ROCKFORD MI
49341-1393
US

IV. Provider business mailing address

6208 KALAMAZOO AVE SE STE 3
GRAND RAPIDS MI
49508-7893
US

V. Phone/Fax

Practice location:
  • Phone: 616-951-3006
  • Fax:
Mailing address:
  • Phone: 616-656-4155
  • Fax: 616-656-4156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MARY VANGEMERT
Title or Position: ADMINISTRATION
Credential:
Phone: 616-656-4155