1053617431 NPI number — HEETLAND ORTHODONTICS PLLC

Table of content: (NPI 1053617431)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053617431 NPI number — HEETLAND ORTHODONTICS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEETLAND ORTHODONTICS PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
HH ORTHO
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053617431
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/03/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2211 MIDWESTERN PKWY
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
WICHITA FALLS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76308-2300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
940-691-2911
Provider Business Mailing Address Fax Number:
940-691-4240

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2211 MIDWESTERN PKWY
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
WICHITA FALLS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76308-2300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
940-691-2911
Provider Business Practice Location Address Fax Number:
940-691-4240
Provider Enumeration Date:
02/02/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HEETLAND
Authorized Official First Name:
KELLY
Authorized Official Middle Name:
Authorized Official Title or Position:
ORTHODONTIST
Authorized Official Telephone Number:
940-691-2911

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  0025867 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)