Provider Demographics
NPI:1336459155
Name:HEYDE, MARILYNN JEAN (BS, RDH, MPH)
Entity Type:Individual
Prefix:
First Name:MARILYNN
Middle Name:JEAN
Last Name:HEYDE
Suffix:
Gender:F
Credentials:BS, RDH, MPH
Other - Prefix:
Other - First Name:MARILYNN
Other - Middle Name:JEAN
Other - Last Name:GOULARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11092 ANDERSON STREET
Mailing Address - Street 2:LLU SCHOOL OF DENTISTRY
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92350-0001
Mailing Address - Country:US
Mailing Address - Phone:909-558-4613
Mailing Address - Fax:909-558-4192
Practice Address - Street 1:11092 ANDERSON STREET
Practice Address - Street 2:LLU SCHOOL OF DENTISTRY
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92350-0001
Practice Address - Country:US
Practice Address - Phone:909-558-4613
Practice Address - Fax:909-558-4192
Is Sole Proprietor?:No
Enumeration Date:2010-10-14
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDH 5781124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARDH 5781OtherSTATE LICENSE