=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356578645
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AUDRA LEANN HIEMSTRA D.D.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2009
-----------------------------------------------------
Last Update Date | 04/09/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14090 FM 2920 RD STE H
-----------------------------------------------------
City | TOMBALL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77377-5550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-516-1222
-----------------------------------------------------
Fax | 866-204-0120
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16510 DUNLEITH CIR
-----------------------------------------------------
City | CYPRESS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77429-4832
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-389-2720
-----------------------------------------------------
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 | 24722
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------