Provider Demographics
NPI:1376028779
Name:KOROMA, HEATHER (DDS)
Entity type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:
Last Name:KOROMA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7231 BURGANDY DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-0254
Mailing Address - Country:US
Mailing Address - Phone:337-499-0377
Mailing Address - Fax:
Practice Address - Street 1:2706 RYAN ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-7328
Practice Address - Country:US
Practice Address - Phone:337-944-0313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-02
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA69271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice