MEDICARE: SKIP TYSON DDS & STEPHANIE HEANEY DDS PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	7278	NC
2	1223P0221X	Pediatric Dentistry	6504	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	9003C	OTHER	NC	BCBS

General Provider Information

NPI Number	:	1083886345
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SKIP TYSON DDS & STEPHANIE HEANEY DDS PA

Provider Business Mailing Address
First Line	:	2606 IRON GATE DR
Second Line	:	SUITE 200
City	:	WILMINGTON
State	:	NC
Zip	:	28412-2573
Country	:	US
Telephone Number	:	910-791-7380
Fax Number	:

Provider Business Practice Location Address
First Line	:	2606 IRON GATE DR
Second Line	:	SUITE 200
City	:	WILMINGTON
State	:	NC
Zip	:	28412-2573
Country	:	US
Telephone Number	:	910-791-7380
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	STEPHANIE HEANEY
Credential	:	DDS
Telephone Number	:	910-791-7380

Provider Enumeration Date	:	03/27/2008
Last Update Date	:	03/27/2008

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