=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164406443
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDGAR ADAM HEIL DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2005
-----------------------------------------------------
Last Update Date | 04/15/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 514 W MAIN ST
-----------------------------------------------------
City | NORWICH
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06360-5321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-889-5166
-----------------------------------------------------
Fax | 860-887-8254
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 514 W MAIN ST
-----------------------------------------------------
City | NORWICH
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06360-5321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-889-5166
-----------------------------------------------------
Fax | 860-887-8254
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 20664
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 009806
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 9806
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------