Provider Demographics
NPI:1053617431
Name:HEETLAND ORTHODONTICS PLLC
Entity type:Organization
Organization Name:HEETLAND ORTHODONTICS PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:HEETLAND
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:940-691-2911
Mailing Address - Street 1:2211 MIDWESTERN PKWY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-2300
Mailing Address - Country:US
Mailing Address - Phone:940-691-2911
Mailing Address - Fax:940-691-4240
Practice Address - Street 1:2211 MIDWESTERN PKWY
Practice Address - Street 2:SUITE 1
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-2300
Practice Address - Country:US
Practice Address - Phone:940-691-2911
Practice Address - Fax:940-691-4240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-02
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX00258671223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty