Provider Demographics
NPI:1083800411
Name:MACKAY, HEIDI (RDHAP)
Entity Type:Individual
Prefix:MRS
First Name:HEIDI
Middle Name:
Last Name:MACKAY
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12927 NEWPORT AVE
Mailing Address - Street 2:#D
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3591
Mailing Address - Country:US
Mailing Address - Phone:949-735-9979
Mailing Address - Fax:
Practice Address - Street 1:12927 NEWPORT AVE
Practice Address - Street 2:#D
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3591
Practice Address - Country:US
Practice Address - Phone:949-735-9979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-19
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHAP123124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z89998-01Medicare PIN