Basic Information
Provider Information
NPI: 1033558309
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: HEILEMANN
FirstName: RICHARD
MiddleName: FRANK
NamePrefix: DR.
NameSuffix:  
Credential: DDS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
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
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X00160000600VTY Dental ProvidersDentist 

ID Information
IDTypeStateIssuerDescription
000172605VT MEDICAID


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