Healthcare Provider Details

I. General information

NPI: 1942369236
Provider Name (Legal Business Name): JOHN D HIESTER, DDS, MSD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1751 E TIPTON ST
SEYMOUR IN
47274-3561
US

IV. Provider business mailing address

1751 E TIPTON ST
SEYMOUR IN
47274-3561
US

V. Phone/Fax

Practice location:
  • Phone: 812-524-8282
  • Fax: 812-522-7289
Mailing address:
  • Phone: 812-524-8282
  • Fax: 812-522-7289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number12009235A
License Number StateIN

VIII. Authorized Official

Name: JOHN D HIESTER
Title or Position: OWNER
Credential: DDS
Phone: 812-524-8282