Provider Demographics
NPI:1609811124
Name:HEATH, WILLIAM TYLER (DMD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:TYLER
Last Name:HEATH
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 1:1107 LOUISA ST
Mailing Address - Street 2:
Mailing Address - City:RAYVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71269-2925
Mailing Address - Country:US
Mailing Address - Phone:318-728-9585
Mailing Address - Fax:318-728-9595
Practice Address - Street 1:1107 LOUISA ST
Practice Address - Street 2:
Practice Address - City:RAYVILLE
Practice Address - State:LA
Practice Address - Zip Code:71269-2925
Practice Address - Country:US
Practice Address - Phone:318-728-9585
Practice Address - Fax:318-728-9595
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-18
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA51101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1851108Medicaid
LA1639484983Medicare UPIN
LA1851108Medicaid
LA1639484983Medicare PIN
LA1639484983Medicare Oscar/Certification