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General NPI Number Information
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NPI Number | 1235243320
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Entity Type | Organization
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Legal Business Name | HEARTLAND PERIODONTICS AND IMPLANT DENTISTRY PC
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Dates
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Enumeration Date | 08/18/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2414 W FAIDLEY AVENUE SUITE 102
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City | GRAND ISLAND
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State | NE
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Zip | 68803-4327
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Country | US
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Telephone | 308-381-2010
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Fax | 308-381-5726
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Provider Business Mailing Address
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Address Line | 2414 W FAIDLEY AVENUE SUITE 102
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City | GRAND ISLAND
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State | NE
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Zip | 68803-4327
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Country | US
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Telephone | 308-381-2010
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Fax | 308-381-5726
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Authorized Official
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Title or Position | PRESIDENT - HEARTLAND PERIODONTICS
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Name | DR. VAN J SANDERFER
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Credential | DDS
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Telephone | 308-381-2010
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 6223
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License Number State | NE
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