Provider Demographics
NPI:1003824525
Name:REYERSON, HEATHER ROSE (DDS)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:ROSE
Last Name:REYERSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2030 7TH ST S
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5202
Mailing Address - Country:US
Mailing Address - Phone:608-782-2812
Mailing Address - Fax:608-782-2815
Practice Address - Street 1:2505 LOOMIS ST
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54603-1973
Practice Address - Country:US
Practice Address - Phone:608-779-4313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5256-015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist