Provider Demographics
NPI:1154931236
Name:WADDELOW, HEATHER MICHELE (LDH)
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:MICHELE
Last Name:WADDELOW
Suffix:
Gender:F
Credentials:LDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3118 S LAFOUNTAIN ST
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-3710
Mailing Address - Country:US
Mailing Address - Phone:765-864-4160
Mailing Address - Fax:
Practice Address - Street 1:3118 S LAFOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3710
Practice Address - Country:US
Practice Address - Phone:765-864-4160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN13004179A124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist