Basic Information
| Provider Information | |||||||||
| NPI: | 1033558309 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEILEMANN | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | FRANK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 74 LONG VIEW DRIVE | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | VT | ||||||||
| PostalCode: | 05254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8023621099 | ||||||||
| FaxNumber: | 8023621901 | ||||||||
| Practice Location | |||||||||
| Address1: | 74 LONG VIEW DRIVE | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER CENTER | ||||||||
| State: | VT | ||||||||
| PostalCode: | 05254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8023621099 | ||||||||
| FaxNumber: | 8023621901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2013 | ||||||||
| LastUpdateDate: | 06/20/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 00160000600 | VT | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 0001726 | 05 | VT | MEDICAID |