Healthcare Provider Details

I. General information

NPI: 1053435594
Provider Name (Legal Business Name): MARK R HEINEMANN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9633 LEVIN RD NW SUITE 206
SILVERDALE WA
98383-8131
US

IV. Provider business mailing address

9633 LEVIN RD NW SUITE 206
SILVERDALE WA
98383-8131
US

V. Phone/Fax

Practice location:
  • Phone: 360-692-3030
  • Fax: 360-692-7720
Mailing address:
  • Phone: 360-692-3030
  • Fax: 360-692-7720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number3816
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: