Basic Information
| Provider Information | |||||||||
| NPI: | 1811965593 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEETER | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | LEEDS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEEDS | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | NICHOLE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DDS | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 931 CHEVY WAY | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975044127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415356239 | ||||||||
| FaxNumber: | 5415121029 | ||||||||
| Practice Location | |||||||||
| Address1: | 1113 PROGRESS DR | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975045201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415123900 | ||||||||
| FaxNumber: | 5414141175 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 02/25/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 21299 | TX | N | Dental Providers | Dentist | General Practice | 1223P0221X | DE60088337 | WA | N | Dental Providers | Dentist | Pediatric Dentistry | 1223P0221X | D10197 | OR | Y | Dental Providers | Dentist | Pediatric Dentistry |
ID Information
| ID | Type | State | Issuer | Description | 1742900-01 | 05 | TX | MEDICAID |