Provider Demographics
NPI:1265635353
Name:MANOGUE, HEATHER M (DMD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:M
Last Name:MANOGUE
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 1:1400 6TH AVE S
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35233-1502
Mailing Address - Country:US
Mailing Address - Phone:205-930-1015
Mailing Address - Fax:205-930-1448
Practice Address - Street 1:1400 6TH AVE S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-1502
Practice Address - Country:US
Practice Address - Phone:205-930-1015
Practice Address - Fax:205-930-1448
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL55891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL110186Medicaid
AL110259Medicaid
AL1861567190OtherGROUP PAYEE NPI
AL515-98179OtherBLUE SHIELD OF ALABAMA
AL110235Medicaid
AL1356417935OtherGROUP PAYEE NPI
AL1245305572OtherGROUP PAYEE NPI
AL515-98178OtherBLUE SHIELD OF ALABAMA
AL1558437905OtherGROUP PAYEE NPI
AL515-98180OtherBLUE SHIELD OF ALABAMA
AL110180Medicaid
AL515-98177OtherBLUE SHIELD OF ALABAMA