Provider Demographics
NPI:1154817138
Name:HEINEKEN, DIANA (DMD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:HEINEKEN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1907 COLUMBIA ST APT 400
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-2219
Mailing Address - Country:US
Mailing Address - Phone:909-844-9829
Mailing Address - Fax:
Practice Address - Street 1:1415 RIDGEBACK RD STE 26
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-6990
Practice Address - Country:US
Practice Address - Phone:619-482-3264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-02
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1026511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty