MEDICARE: HERITAGE LEGACY DENTAL CARE, INC

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	122300000X	Dentist	3220	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1659819738
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HERITAGE LEGACY DENTAL CARE, INC

Provider Business Mailing Address
First Line	:	7 EDENWOOD LN
Second Line	:
City	:	N LITTLE ROCK
State	:	AR
Zip	:	72116-5105
Country	:	US
Telephone Number	:	501-771-4500
Fax Number	:	901-763-3573

Provider Business Practice Location Address
First Line	:	7 EDENWOOD LN
Second Line	:
City	:	N LITTLE ROCK
State	:	AR
Zip	:	72116-5105
Country	:	US
Telephone Number	:	501-771-4500
Fax Number	:	901-763-3573

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. WADE ROBERTSON
Credential	:	DDS
Telephone Number	:	501-771-4500

Provider Enumeration Date	:	02/08/2017
Last Update Date	:	02/08/2017

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