Provider Demographics
NPI:1134137474
Name:HEATON, WILSON P (DDS)
Entity Type:Individual
Prefix:DR
First Name:WILSON
Middle Name:P
Last Name:HEATON
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 1:4435 W 95TH ST
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2625
Mailing Address - Country:US
Mailing Address - Phone:708-423-5990
Mailing Address - Fax:708-423-8552
Practice Address - Street 1:4435 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2625
Practice Address - Country:US
Practice Address - Phone:708-423-5990
Practice Address - Fax:708-423-8552
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
L08503Medicare PIN
K20896Medicare PIN
K20895Medicare PIN
L08501Medicare PIN