Provider Demographics
NPI:1467599894
Name:HEISERMAN, KARL G (DDS)
Entity Type:Individual
Prefix:DR
First Name:KARL
Middle Name:G
Last Name:HEISERMAN
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 1:1613 JIMMIE DAVIS HWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71112-4557
Mailing Address - Country:US
Mailing Address - Phone:318-742-0096
Mailing Address - Fax:
Practice Address - Street 1:1613 JIMMIE DAVIS HWY
Practice Address - Street 2:SUITE 300
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71112-4557
Practice Address - Country:US
Practice Address - Phone:318-742-0096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA36931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice