MEDICARE: DR. EMMA KATHLEEN O'HEENEY DMD

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	122300000X	Dentist	12013201A	IN

General Provider Information

NPI Number	:	1669025037
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EMMA KATHLEEN O'HEENEY DMD

Provider Business Mailing Address
First Line	:	9405 ILLINOIS RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-5795
Country	:	US
Telephone Number	:	260-452-9014
Fax Number	:

Provider Business Practice Location Address
First Line	:	9405 ILLINOIS RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-5795
Country	:	US
Telephone Number	:	260-452-9014
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/24/2019
Last Update Date	:	07/24/2019

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