Provider Demographics
NPI:1760764518
Name:HEATON, JONATHAN K (DMD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:K
Last Name:HEATON
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 1:703 N DUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-6101
Mailing Address - Country:US
Mailing Address - Phone:505-564-9700
Mailing Address - Fax:
Practice Address - Street 1:703 N DUSTIN AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6101
Practice Address - Country:US
Practice Address - Phone:505-564-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-16
Last Update Date:2015-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD43761223G0001X
NMDD37661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice