Provider Demographics
NPI:1760037758
Name:HEITMAN, PETER FREDERICK (DMD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:FREDERICK
Last Name:HEITMAN
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:CDR US ARMY DENTAL ACTIVITY
Mailing Address - Street 2:2441 21ST STREET
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:TN
Mailing Address - Zip Code:37040
Mailing Address - Country:US
Mailing Address - Phone:270-798-8977
Mailing Address - Fax:
Practice Address - Street 1:USA DENTAL ACTIVITY
Practice Address - Street 2:652 HAMILTON RD.
Practice Address - City:FORT SILL
Practice Address - State:OK
Practice Address - Zip Code:73503
Practice Address - Country:US
Practice Address - Phone:580-442-5488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-06
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9383122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist