Provider Demographics
NPI:1730372012
Name:HEARTLAND FAMILY DENTAL CARE OF ILLINOIS, PC
Entity type:Organization
Organization Name:HEARTLAND FAMILY DENTAL CARE OF ILLINOIS, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INS COORD
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:KROEGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:314 W KIRBY AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-7208
Mailing Address - Country:US
Mailing Address - Phone:217-366-8371
Mailing Address - Fax:217-366-8372
Practice Address - Street 1:314 W KIRBY AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7208
Practice Address - Country:US
Practice Address - Phone:217-366-8371
Practice Address - Fax:217-366-8372
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEARTLAND FAMILY DENTAL CARE OF ILLINOIS, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-21
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty