=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609879667
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | J MICHAEL HEIDER DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2026 NE 19TH ST
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33305-2509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-566-5428
-----------------------------------------------------
Fax | 954-564-6043
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2026 NE 19TH ST
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33305-2509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-566-5428
-----------------------------------------------------
Fax | 954-564-6043
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN00009225
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------