Provider Demographics
NPI:1497074231
Name:HIGSON, ETHAN FOSTER (DMD)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:FOSTER
Last Name:HIGSON
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:PO BOX 2567
Mailing Address - Street 2:
Mailing Address - City:CHINLE
Mailing Address - State:AZ
Mailing Address - Zip Code:86503-2567
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:HIGHWAY 191 & HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:CHINLE
Practice Address - State:AZ
Practice Address - Zip Code:86503
Practice Address - Country:US
Practice Address - Phone:928-674-7001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-19
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY88771223D0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program