Basic Information
| Provider Information | |||||||||
| NPI: | 1700334273 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHUTA | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | |||||||||
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| Credential: | RDH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7101 HOFF ST BLDG 9240 | ||||||||
| Address2: | USA DENTAL ACTIVITY | ||||||||
| City: | FORT BENNING | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319055645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065443103 | ||||||||
| FaxNumber: | 7065441933 | ||||||||
| Practice Location | |||||||||
| Address1: | 7101 HOFF ST BLDG 9240 | ||||||||
| Address2: | USA DENTAL ACTIVITY | ||||||||
| City: | FORT BENNING | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319055645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065443103 | ||||||||
| FaxNumber: | 7065441933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2016 | ||||||||
| LastUpdateDate: | 09/14/2016 | ||||||||
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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 | DH011499 | GA | Y | Dental Providers | Dental Hygienist | 124Q00000X | H.007822-C1 | AL | N | Dental Providers | Dental Hygienist |
No ID Information.