Healthcare Provider Details

I. General information

NPI: 1396498069
Provider Name (Legal Business Name): EMILY HEFFNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2022
Last Update Date: 11/03/2026
Certification Date: 11/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BLUE MOON XING STE 103
POOLER GA
31322-9809
US

IV. Provider business mailing address

100 BLUE MOON XING STE 103
POOLER GA
31322-9809
US

V. Phone/Fax

Practice location:
  • Phone: 912-737-4044
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN124169
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: