Provider Demographics
NPI:1760736789
Name:SHAFER, HEATHER K (RDH)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:K
Last Name:SHAFER
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 1:5204 E AGAVE VISTA DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85756-8685
Mailing Address - Country:US
Mailing Address - Phone:520-358-6924
Mailing Address - Fax:
Practice Address - Street 1:5204 E AGAVE VISTA DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85756-8685
Practice Address - Country:US
Practice Address - Phone:520-358-6924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZH06310124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist