=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336436906
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUSTIN ANTHONY HEATON DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2011
-----------------------------------------------------
Last Update Date | 04/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 NE 139TH ST STE 106
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98685
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-604-9000
-----------------------------------------------------
Fax | 360-573-1417
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5417 NE 265TH ST
-----------------------------------------------------
City | RIDGEFIELD
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98642-7713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-569-4169
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DE60739379
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | DE60739379
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------