Provider Demographics
NPI:1740263359
Name:HEATON, KENNETH GORDON JR (DDS)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:GORDON
Last Name:HEATON
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:737 W CHILDS AVE
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95340-6805
Mailing Address - Country:US
Mailing Address - Phone:209-383-1848
Mailing Address - Fax:209-384-3966
Practice Address - Street 1:725 W I ST
Practice Address - Street 2:
Practice Address - City:LOS BANOS
Practice Address - State:CA
Practice Address - Zip Code:93635-3478
Practice Address - Country:US
Practice Address - Phone:209-826-1094
Practice Address - Fax:209-826-7808
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA417311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABH4267604OtherDEA CERT