Provider Demographics
NPI:1023375235
Name:HEAPE, BRANNON W (DMD, MD)
Entity Type:Individual
Prefix:
First Name:BRANNON
Middle Name:W
Last Name:HEAPE
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 PHYSICIANS DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7352
Mailing Address - Country:US
Mailing Address - Phone:910-762-2618
Mailing Address - Fax:910-763-5173
Practice Address - Street 1:2971 CORPORATE PARK DR
Practice Address - Street 2:
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36801-7283
Practice Address - Country:US
Practice Address - Phone:334-749-3436
Practice Address - Fax:334-749-3223
Is Sole Proprietor?:No
Enumeration Date:2012-04-13
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X, 390200000X
ALD.59411223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program