MEDICARE: DR. HEATHER LOUISE PHARES D.D.S.

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	017662	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1810072	OTHER	MI	UNITED CONCORDIA
2	D176620	OTHER	MI	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1942397757
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HEATHER LOUISE PHARES D.D.S.

Provider Business Mailing Address
First Line	:	4711 FIRST STREET
Second Line	:
City	:	NEW ERA
State	:	MI
Zip	:	49446
Country	:	US
Telephone Number	:	231-861-5905
Fax Number	:	231-861-4764

Provider Business Practice Location Address
First Line	:	4711 FIRST STREET
Second Line	:
City	:	NEW ERA
State	:	MI
Zip	:	49446
Country	:	US
Telephone Number	:	231-861-5905
Fax Number	:	231-861-4764

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

Provider Enumeration Date	:	10/05/2006
Last Update Date	:	07/08/2007

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