Provider Demographics
NPI:1801980925
Name:DAITCH, HEATHER GAYLE (DDS)
Entity type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:GAYLE
Last Name:DAITCH
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 1:2819 ORCHARD LAKE RD
Mailing Address - Street 2:
Mailing Address - City:KEEGO HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48320-1448
Mailing Address - Country:US
Mailing Address - Phone:248-683-2323
Mailing Address - Fax:
Practice Address - Street 1:2819 ORCHARD LAKE RD
Practice Address - Street 2:
Practice Address - City:KEEGO HARBOR
Practice Address - State:MI
Practice Address - Zip Code:48320-1448
Practice Address - Country:US
Practice Address - Phone:248-683-2323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI188511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice