Provider Demographics
NPI:1922104082
Name:HEIDEMAN, GREGORY (DMD)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:
Last Name:HEIDEMAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6816 ROYAL POINCIANA CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89131-1769
Mailing Address - Country:US
Mailing Address - Phone:702-677-6270
Mailing Address - Fax:
Practice Address - Street 1:6950 SMOKE RANCH RD STE 150
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-1301
Practice Address - Country:US
Practice Address - Phone:702-304-1902
Practice Address - Fax:702-304-1909
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV48451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice