Healthcare Provider Details

I. General information

NPI: 1336436906
Provider Name (Legal Business Name): JUSTIN ANTHONY HEATON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2011
Last Update Date: 04/03/2025
Certification Date: 04/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 NE 139TH ST STE 106
VANCOUVER WA
98685
US

IV. Provider business mailing address

5417 NE 265TH ST
RIDGEFIELD WA
98642-7713
US

V. Phone/Fax

Practice location:
  • Phone: 360-604-9000
  • Fax: 360-573-1417
Mailing address:
  • Phone: 208-569-4169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE60739379
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDE60739379
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: