Ellie Heydari, DDS

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

7252-15 Issued in WI

Practice address

36745 Aiken Rd.
Red Cliff Community Health Center
Bayfield, WI 54814

Phone

(715) 779-3707

Fax

(715) 779-3622

NPI assigned

Mar 5, 2008

Last updated

Feb 10, 2017By the provider in NPPES

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in TX

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Department of Health & Human Services PHS IHS

  • Critical Access Hospital
  • Cass Lake, MN
  • NPI 1194754382

  TX

  Medicare reassignment NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1204675200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1486684800000",
    "number": "1518137652",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "36745 AIKEN RD",
            "address_2": "36745 AIKEN RD.",
            "city": "BAYFIELD",
            "state": "WI",
            "postal_code": "548144579",
            "telephone_number": "715-779-3707",
            "fax_number": "715-779-3622"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "36745 AIKEN RD.",
            "address_2": "RED CLIFF COMMUNITY HEALTH CENTER",
            "city": "BAYFIELD",
            "state": "WI",
            "postal_code": "54814",
            "telephone_number": "715-779-3707",
            "fax_number": "715-779-3622"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "HEYDARI",
        "first_name": "ELLIE",
        "credential": "DDS",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2008-03-05",
        "last_updated": "2017-02-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "MI",
            "license": "2901017468",
            "primary": false
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "WI",
            "license": "7252-15",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Martin A Gordon
• Isabel Georgiane Gregersen, LCSW
• Melissa Grooms, MS
• Nicole Renee Gurnoe
• Grace M Heitsch, M.D.
• Allyssa Kimberly Hoopman
• Patricia M. Kenote-Deperry
• Tamara L Kolesar, LPC-IT, SAC-IT
• Jennifer Kupczyk, PHARM.D.
• Gail Marie Lemieux, SAC

• General Practice Dentistry in Bayfield, WI
• Providers in Bayfield, WI by specialty
• General Practice Dentistry in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 10, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.