Healthcare Provider Details

I. General information

NPI: 1134564552
Provider Name (Legal Business Name): WILLIAM W HEITZMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2013
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 1ST AVE E
SHAKOPEE MN
55379-1439
US

IV. Provider business mailing address

415 1ST AVE E
SHAKOPEE MN
55379-1439
US

V. Phone/Fax

Practice location:
  • Phone: 952-403-5149
  • Fax: 952-403-5969
Mailing address:
  • Phone: 952-403-5149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code125J00000X
TaxonomyDental Therapist
License NumberDT18
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: