Provider Demographics
NPI:1821182577
Name:HEATHMAN, MONTGOMERY D (DDS)
Entity Type:Individual
Prefix:DR
First Name:MONTGOMERY
Middle Name:D
Last Name:HEATHMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12501 CANTRELL RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223-1639
Mailing Address - Country:US
Mailing Address - Phone:501-223-3838
Mailing Address - Fax:
Practice Address - Street 1:12501 CANTRELL RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72223-1639
Practice Address - Country:US
Practice Address - Phone:501-223-3838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR33331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR161458608Medicaid