Healthcare Provider Details

I. General information

NPI: 1699542761
Provider Name (Legal Business Name): JENNA ILANA HEITZLER DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2023
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6047 TRANSIT RD STE 101
EAST AMHERST NY
14051-2099
US

IV. Provider business mailing address

610 RIVER RD UNIT 2
NORTH TONAWANDA NY
14120-6572
US

V. Phone/Fax

Practice location:
  • Phone: 914-815-4873
  • Fax:
Mailing address:
  • Phone: 914-815-4873
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number22DI03007400
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number065443
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: