Basic Information
| Provider Information | |||||||||
| NPI: | 1578961652 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | HEIDSHA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | RDH | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 758 | ||||||||
| Address2: | 475 NELSON AVE | ||||||||
| City: | NEOSHO | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4174510619 | ||||||||
| FaxNumber: | 4174518903 | ||||||||
| Practice Location | |||||||||
| Address1: | 927 N 71 BUSINESS HWY | ||||||||
| Address2: | |||||||||
| City: | ANDERSON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178452273 | ||||||||
| FaxNumber: | 4178458314 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2014 | ||||||||
| LastUpdateDate: | 12/05/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 2010031334 | MO | Y | Dental Providers | Dental Hygienist |
No ID Information.