MEDICARE: HERITAGE FAMILY DENTAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	12011723A	IN

General Provider Information

NPI Number	:	1154693752
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HERITAGE FAMILY DENTAL

Provider Business Mailing Address
First Line	:	731 N GREEN RIVER RD
Second Line	:
City	:	EVANSVILLE
State	:	IN
Zip	:	47715-2415
Country	:	US
Telephone Number	:	812-476-3002
Fax Number	:	812-476-3027

Provider Business Practice Location Address
First Line	:	731 N GREEN RIVER RD
Second Line	:
City	:	EVANSVILLE
State	:	IN
Zip	:	47715-2415
Country	:	US
Telephone Number	:	812-476-3002
Fax Number	:	812-476-3027

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	NISSA MCCONNELL
Credential	:
Telephone Number	:	812-476-3002

Provider Enumeration Date	:	01/30/2012
Last Update Date	:	01/30/2012

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