Provider Demographics
NPI:1003905845
Name:HEISE, KENNETH R (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:R
Last Name:HEISE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 N MARKET ST
Mailing Address - Street 2:
Mailing Address - City:ELYSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17824
Mailing Address - Country:US
Mailing Address - Phone:570-672-9692
Mailing Address - Fax:570-672-1019
Practice Address - Street 1:11 N MARKET ST
Practice Address - Street 2:
Practice Address - City:ELYSBURG
Practice Address - State:PA
Practice Address - Zip Code:17824
Practice Address - Country:US
Practice Address - Phone:570-672-9692
Practice Address - Fax:570-672-1019
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS023434L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist