Basic Information
| Provider Information | |||||||||
| NPI: | 1487989356 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACKEY | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | R.D.H. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1136 | ||||||||
| Address2: | |||||||||
| City: | ANDERSON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648311136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178452273 | ||||||||
| FaxNumber: | 4178452253 | ||||||||
| Practice Location | |||||||||
| Address1: | 508 W HIGHWAY 76 | ||||||||
| Address2: | |||||||||
| City: | ANDERSON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648318548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178452243 | ||||||||
| FaxNumber: | 7148452253 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2009 | ||||||||
| LastUpdateDate: | 10/12/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 126800000X | 003679 | MO | Y | Dental Providers | Dental Assistant |
No ID Information.