Provider Demographics
NPI:1578961652
Name:PETERSON, HEIDSHA L (RDH)
Entity Type:Individual
Prefix:MRS
First Name:HEIDSHA
Middle Name:L
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RDH
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 758
Mailing Address - Street 2:475 NELSON AVE
Mailing Address - City:NEOSHO
Mailing Address - State:MO
Mailing Address - Zip Code:64850
Mailing Address - Country:US
Mailing Address - Phone:417-451-0619
Mailing Address - Fax:417-451-8903
Practice Address - Street 1:927 N 71 BUSINESS HWY
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:MO
Practice Address - Zip Code:64831
Practice Address - Country:US
Practice Address - Phone:417-845-2273
Practice Address - Fax:417-845-8314
Is Sole Proprietor?:No
Enumeration Date:2014-12-05
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010031334124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist