Provider Demographics
NPI:1982014965
Name:HEAVENER, KIRSTEN (DDS)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:
Last Name:HEAVENER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:KIRSTEN
Other - Middle Name:
Other - Last Name:LOGSDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:839 WINDSOR RD
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-2729
Mailing Address - Country:US
Mailing Address - Phone:301-876-8212
Mailing Address - Fax:
Practice Address - Street 1:12503 WILLOWBROOK RD
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-2554
Practice Address - Country:US
Practice Address - Phone:301-759-5030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-30
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD158651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice