Provider Demographics
NPI:1780895219
Name:HEIDEMAN, KENT A (DDS)
Entity type:Individual
Prefix:DR
First Name:KENT
Middle Name:A
Last Name:HEIDEMAN
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 1:195 W TELEGRAPH ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84780-1675
Mailing Address - Country:US
Mailing Address - Phone:435-673-4605
Mailing Address - Fax:
Practice Address - Street 1:195 W TELEGRAPH ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:UT
Practice Address - Zip Code:84780-1675
Practice Address - Country:US
Practice Address - Phone:435-673-4605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1411131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice