Healthcare Provider Details

I. General information

NPI: 1083787386
Provider Name (Legal Business Name): BRIAN TORY HEINE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 10/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 LONE OAK RD STE #6
PADUCAH KY
42003-8043
US

IV. Provider business mailing address

2850 LONE OAK RD STE #6
PADUCAH KY
42003-8043
US

V. Phone/Fax

Practice location:
  • Phone: 270-554-2026
  • Fax: 270-554-2028
Mailing address:
  • Phone: 270-554-2026
  • Fax: 270-554-2028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number6942
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number6942
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number6942
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: