Provider Demographics
NPI:1700334273
Name:SHUTA, HEATHER (RDH)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:SHUTA
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 1:7101 HOFF ST BLDG 9240
Mailing Address - Street 2:USA DENTAL ACTIVITY
Mailing Address - City:FORT BENNING
Mailing Address - State:GA
Mailing Address - Zip Code:31905-5645
Mailing Address - Country:US
Mailing Address - Phone:706-544-3103
Mailing Address - Fax:706-544-1933
Practice Address - Street 1:7101 HOFF ST BLDG 9240
Practice Address - Street 2:USA DENTAL ACTIVITY
Practice Address - City:FORT BENNING
Practice Address - State:GA
Practice Address - Zip Code:31905-5645
Practice Address - Country:US
Practice Address - Phone:706-544-3103
Practice Address - Fax:706-544-1933
Is Sole Proprietor?:No
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADH011499124Q00000X
ALH.007822-C1124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist