Healthcare Provider Details

I. General information

NPI: 1073778668
Provider Name (Legal Business Name): LOUIS H. HEITKE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2008
Last Update Date: 07/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 E JOHNSON ST
MADISON WI
53703-2120
US

IV. Provider business mailing address

122 E JOHNSON ST
MADISON WI
53703-2120
US

V. Phone/Fax

Practice location:
  • Phone: 608-257-0116
  • Fax: 608-257-8901
Mailing address:
  • Phone: 608-257-0116
  • Fax: 608-257-8901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2469
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: