Provider Demographics
NPI:1487647863
Name:HIEMER, JONATHAN W (DMD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:W
Last Name:HIEMER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6604 BARDSTOWN RD
Mailing Address - Street 2:SUITE: B
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40291-3045
Mailing Address - Country:US
Mailing Address - Phone:502-239-6850
Mailing Address - Fax:502-239-3425
Practice Address - Street 1:6604 BARDSTOWN RD
Practice Address - Street 2:SUITE: B
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40291-3045
Practice Address - Country:US
Practice Address - Phone:502-239-6850
Practice Address - Fax:502-239-3425
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6188122300000X, 1223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYY292OtherBCBS PROVIDER NUMBER
KY60061884Medicaid
KY469970OtherUNITED CONCORDIA
KY6342OtherPASSPORT PROVIDER NUMBER