Provider Demographics
NPI:1083605729
Name:HEISCH, LAURA DENISE (DDS)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:DENISE
Last Name:HEISCH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:LAURA
Other - Middle Name:DENISE
Other - Last Name:LEFEVERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:106 A LONGVIEW DR
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544-3738
Mailing Address - Country:US
Mailing Address - Phone:505-672-1336
Mailing Address - Fax:505-672-0840
Practice Address - Street 1:106 A LONGVIEW DR
Practice Address - Street 2:
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-3738
Practice Address - Country:US
Practice Address - Phone:505-672-1336
Practice Address - Fax:505-672-0840
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD1751122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM4554Medicaid
NMR9365Medicaid