Provider Demographics
NPI:1669550869
Name:HEITMAN, MERCEDES A (DDS)
Entity type:Individual
Prefix:
First Name:MERCEDES
Middle Name:A
Last Name:HEITMAN
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 1:1416 PROFESSIONAL DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954
Mailing Address - Country:US
Mailing Address - Phone:707-769-1162
Mailing Address - Fax:707-769-9687
Practice Address - Street 1:1416 PROFESSIONAL DR
Practice Address - Street 2:SUITE 202
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954
Practice Address - Country:US
Practice Address - Phone:707-769-1162
Practice Address - Fax:707-769-9687
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA310771223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics