Provider Demographics
NPI:1275633018
Name:HEATER, LARRY (DDS)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:
Last Name:HEATER
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 1:107 H. ST. EAST
Mailing Address - Street 2:
Mailing Address - City:POPLAR
Mailing Address - State:MT
Mailing Address - Zip Code:59255
Mailing Address - Country:US
Mailing Address - Phone:406-768-2129
Mailing Address - Fax:406-768-3423
Practice Address - Street 1:107 H. ST. EAST
Practice Address - Street 2:
Practice Address - City:POPLAR
Practice Address - State:MT
Practice Address - Zip Code:59255
Practice Address - Country:US
Practice Address - Phone:406-768-2129
Practice Address - Fax:406-786-3423
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24113122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA24113OtherCALIFORNIA STATE BOARD
MT2210068Medicaid