Provider Demographics
NPI:1811965593
Name:HEETER, KIMBERLY LEEDS (DDS)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:LEEDS
Last Name:HEETER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:KIMBERLY
Other - Middle Name:NICHOLE
Other - Last Name:LEEDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:931 CHEVY WAY
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4127
Mailing Address - Country:US
Mailing Address - Phone:541-535-6239
Mailing Address - Fax:541-512-1029
Practice Address - Street 1:1113 PROGRESS DR
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-5201
Practice Address - Country:US
Practice Address - Phone:541-512-3900
Practice Address - Fax:541-414-1175
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX212991223G0001X
WADE600883371223P0221X
ORD101971223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1742900-01Medicaid