MEDICARE: MR. GREGORY HEIDEMAN D.M.D.

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	4845	NV

General Provider Information

NPI Number	:	1922104082
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GREGORY HEIDEMAN D.M.D.

Provider Business Mailing Address
First Line	:	6816 ROYAL POINCIANA CT
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89131-1769
Country	:	US
Telephone Number	:	702-677-6270
Fax Number	:

Provider Business Practice Location Address
First Line	:	6950 SMOKE RANCH RD STE 150
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-1301
Country	:	US
Telephone Number	:	702-304-1902
Fax Number	:	702-304-1909

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	08/18/2015

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