Provider Demographics
NPI:1063419125
Name:CROUCH, HEATHER ANNE (DDS)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:ANNE
Last Name:CROUCH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1798 S WEST TEMPLE
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84115-1874
Mailing Address - Country:US
Mailing Address - Phone:801-412-6933
Mailing Address - Fax:801-412-6950
Practice Address - Street 1:1365 W 1000 N
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84116-1654
Practice Address - Country:US
Practice Address - Phone:801-328-5756
Practice Address - Fax:801-521-7463
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5607872-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU99671Medicare UPIN