Healthcare Provider Details

I. General information

NPI: 1083671051
Provider Name (Legal Business Name): MICHAEL LEO HEMKER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 08/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG 557 STERNBERG AVENUE FT EUSTIS DENTAC
FORT EUSTIS VA
23604-5311
US

IV. Provider business mailing address

BLDG 557 STERNBERG AVENUE FT EUSTIS DENTAC
FORT EUSTIS VA
23604-5311
US

V. Phone/Fax

Practice location:
  • Phone: 757-314-7944
  • Fax:
Mailing address:
  • Phone: 757-314-7944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number17543
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number17543
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: