MEDICARE: C. R. HEIRTZLER, JR., D.D.S., 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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	6682	TX

General Provider Information

NPI Number	:	1942473178
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	C. R. HEIRTZLER, JR., D.D.S., INC.

Provider Business Mailing Address
First Line	:	3312 MEDICAL TRIANGLE DRIVE
Second Line	:
City	:	PORT ARTHUR
State	:	TX
Zip	:	77642-2424
Country	:	US
Telephone Number	:	409-962-5311
Fax Number	:	409-963-3192

Provider Business Practice Location Address
First Line	:	3312 MEDICAL TRIANGLE DRIVE
Second Line	:
City	:	PORT ARTHUR
State	:	TX
Zip	:	77642-2424
Country	:	US
Telephone Number	:	409-962-5311
Fax Number	:	409-963-3192

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	DR. CLARENCE R HEIRTZLER JR.
Credential	:	D.D.S.
Telephone Number	:	409-962-5311

Provider Enumeration Date	:	04/09/2008
Last Update Date	:	04/09/2008

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