Provider Demographics
NPI:1417361932
Name:KEITH, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:KEITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 WESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-2102
Mailing Address - Country:US
Mailing Address - Phone:660-826-4774
Mailing Address - Fax:660-826-1300
Practice Address - Street 1:821 WESTWOOD DR
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-2102
Practice Address - Country:US
Practice Address - Phone:660-826-4774
Practice Address - Fax:660-826-1300
Is Sole Proprietor?:No
Enumeration Date:2014-06-12
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014017360122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist