Provider Demographics
NPI:1376654905
Name:HEIST, ROBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:HEIST
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 1:2051 KAEN RD
Mailing Address - Street 2:367
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-4035
Mailing Address - Country:US
Mailing Address - Phone:503-650-3110
Mailing Address - Fax:503-742-5979
Practice Address - Street 1:9775 SE SUNNYSIDE RD
Practice Address - Street 2:200
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-5739
Practice Address - Country:US
Practice Address - Phone:503-655-8471
Practice Address - Fax:503-723-4907
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30015652122300000X
ORD8746122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORD8746OtherSTATE LICENCE NUMBER
OH099071Medicaid
R103163OtherMEDICARE PART B
OR168395Medicaid
OH099071Medicaid