Provider Demographics
NPI:1083787386
Name:HEINE, BRIAN TORY (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:TORY
Last Name:HEINE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2850 LONE OAK RD STE #6
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-8043
Mailing Address - Country:US
Mailing Address - Phone:270-554-2026
Mailing Address - Fax:270-554-2028
Practice Address - Street 1:2850 LONE OAK RD STE #6
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-8043
Practice Address - Country:US
Practice Address - Phone:270-554-2026
Practice Address - Fax:270-554-2028
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6942204E00000X, 122300000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U84875Medicare UPIN
KY1878001Medicare ID - Type Unspecified