Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | DS023434L | PA |
NPI | 1003905845 |
---|---|
Provider Name | Dr. Kenneth R Heise |
First Address | Elysburg, PA 17824 |
Second Address | Elysburg, PA 17824 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/10/2006 |
Last Update Date | 08/07/2007 |