=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154693752
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HERITAGE FAMILY DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2012
-----------------------------------------------------
Last Update Date | 01/30/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 731 N GREEN RIVER RD
-----------------------------------------------------
City | EVANSVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47715-2415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-476-3002
-----------------------------------------------------
Fax | 812-476-3027
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 731 N GREEN RIVER RD
-----------------------------------------------------
City | EVANSVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47715-2415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-476-3002
-----------------------------------------------------
Fax | 812-476-3027
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | NISSA MCCONNELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 812-476-3002
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 12011723A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------