Provider Demographics
NPI:1124287123
Name:CROCKETT-MILLER, HEATHER MARIE (DDS)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:MARIE
Last Name:CROCKETT-MILLER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:CROCKETT-WASHINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:575 MAIN ST FL 2
Mailing Address - Street 2:ATTN: CREDENTIALING DEPT
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-2845
Mailing Address - Country:US
Mailing Address - Phone:860-347-6971
Mailing Address - Fax:
Practice Address - Street 1:1160 W BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43222-1352
Practice Address - Country:US
Practice Address - Phone:614-274-1455
Practice Address - Fax:614-274-1433
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-04
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0104711223G0001X
OH30.0230111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0189670Medicaid