Healthcare Provider Details

I. General information

NPI: 1740263359
Provider Name (Legal Business Name): KENNETH GORDON HEATON JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 W I ST
LOS BANOS CA
93635-3478
US

IV. Provider business mailing address

737 W CHILDS AVE
MERCED CA
95340-6805
US

V. Phone/Fax

Practice location:
  • Phone: 209-826-1094
  • Fax: 209-826-7808
Mailing address:
  • Phone: 209-383-1848
  • Fax: 209-384-3966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number41731
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: