Healthcare Provider Details

I. General information

NPI: 1154517837
Provider Name (Legal Business Name): JEFFREY HIESTER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2007
Last Update Date: 09/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7200 E VIRGINIA STREET
EVANSVILLE IN
47715
US

IV. Provider business mailing address

7200 E VIRGINIA STREET
EVANSVILLE IN
47715
US

V. Phone/Fax

Practice location:
  • Phone: 812-479-8609
  • Fax: 812-479-5554
Mailing address:
  • Phone: 812-479-8609
  • Fax: 812-479-5554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number12010159A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: