Basic Information
| Provider Information | |||||||||
| NPI: | 1740263359 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEATON | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | GORDON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 737 W CHILDS AVE | ||||||||
| Address2: | |||||||||
| City: | MERCED | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953406805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093831848 | ||||||||
| FaxNumber: | 2093843966 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 W I ST | ||||||||
| Address2: | |||||||||
| City: | LOS BANOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936353478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2098261094 | ||||||||
| FaxNumber: | 2098267808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2005 | ||||||||
| LastUpdateDate: | 01/09/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 41731 | CA | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | BH4267604 | 01 | CA | DEA CERT | OTHER |