Provider Demographics
NPI:1649471855
Name:HEIZER, JONATHAN RAY (DDS)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:RAY
Last Name:HEIZER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 W PEARL ST
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76048-2051
Mailing Address - Country:US
Mailing Address - Phone:817-573-3724
Mailing Address - Fax:817-573-9251
Practice Address - Street 1:915 W PEARL ST
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-2051
Practice Address - Country:US
Practice Address - Phone:817-573-3724
Practice Address - Fax:817-573-9251
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX217191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice