Provider Demographics
NPI:1083886345
Name:SKIP TYSON DDS & STEPHANIE HEANEY DDS PA
Entity Type:Organization
Organization Name:SKIP TYSON DDS & STEPHANIE HEANEY DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HEANEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:910-791-7380
Mailing Address - Street 1:2606 IRON GATE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-2573
Mailing Address - Country:US
Mailing Address - Phone:910-791-7380
Mailing Address - Fax:
Practice Address - Street 1:2606 IRON GATE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-2573
Practice Address - Country:US
Practice Address - Phone:910-791-7380
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-27
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC65041223P0221X
NC72781223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89903CMedicaid
NC9003COtherBCBS