Provider Demographics
NPI:1932405180
Name:HEETLAND, KELLY (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:HEETLAND
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2211 MIDWESTERN PKWY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-2300
Mailing Address - Country:US
Mailing Address - Phone:940-691-2911
Mailing Address - Fax:940-691-4240
Practice Address - Street 1:2211 MIDWESTERN PKWY
Practice Address - Street 2:SUITE 1
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-2300
Practice Address - Country:US
Practice Address - Phone:940-691-2911
Practice Address - Fax:940-691-4240
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-07
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX00258671223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics