Provider Demographics
NPI:1730552050
Name:STACK, HEATHER (RDH)
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:
Last Name:STACK
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21334 US HIGHWAY 12
Mailing Address - Street 2:
Mailing Address - City:EDWARDSBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49112-9240
Mailing Address - Country:US
Mailing Address - Phone:269-228-8500
Mailing Address - Fax:269-445-1928
Practice Address - Street 1:261 M 62
Practice Address - Street 2:
Practice Address - City:CASSOPOLIS
Practice Address - State:MI
Practice Address - Zip Code:49031-1034
Practice Address - Country:US
Practice Address - Phone:269-228-8500
Practice Address - Fax:269-445-1928
Is Sole Proprietor?:No
Enumeration Date:2015-11-09
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902016335124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist