Provider Demographics
NPI:1396379335
Name:BAUGHMAN, HEATHER MARIE (DDS)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:MARIE
Last Name:BAUGHMAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2355 E DALTON AVE
Mailing Address - Street 2:
Mailing Address - City:DALTON GARDENS
Mailing Address - State:ID
Mailing Address - Zip Code:83815-9614
Mailing Address - Country:US
Mailing Address - Phone:208-755-6691
Mailing Address - Fax:
Practice Address - Street 1:483 N AVIATION BLVD BLDG 210
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-2808
Practice Address - Country:US
Practice Address - Phone:310-653-6844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-28
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IDD-51391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program