Healthcare Provider Details

I. General information

NPI: 1568564516
Provider Name (Legal Business Name): MICHAEL THOMAS HEILAND DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 04/08/2021
Certification Date: 04/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5650 MEXICO RD STE 5
SAINT PETERS MO
63376-1696
US

IV. Provider business mailing address

PO BOX 326
COTTLEVILLE MO
63338-0326
US

V. Phone/Fax

Practice location:
  • Phone: 636-447-6665
  • Fax: 636-447-2973
Mailing address:
  • Phone: 314-616-4201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14724
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: