Basic Information
Provider Information | |||||||||
NPI: | 1881858637 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HADDOX-HESTON | ||||||||
FirstName: | LISA | ||||||||
MiddleName: | JAN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.D.S. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7400 LYNN AVE | ||||||||
Address2: |   | ||||||||
City: | HAMLIN | ||||||||
State: | WV | ||||||||
PostalCode: | 255231138 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3048245806 | ||||||||
FaxNumber: | 3048245804 | ||||||||
Practice Location | |||||||||
Address1: | 1 WILDCAT WAY | ||||||||
Address2: |   | ||||||||
City: | LOGAN | ||||||||
State: | WV | ||||||||
PostalCode: | 256013474 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3046889949 | ||||||||
FaxNumber: | 3046889953 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/10/2008 | ||||||||
LastUpdateDate: | 04/28/2015 | ||||||||
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 | 122300000X | 2962 | WV | Y |   | Dental Providers | Dentist |   |
No ID Information.