Provider Demographics
NPI:1275836447
Name:HEITZMANN DENTISTRY
Entity Type:Organization
Organization Name:HEITZMANN DENTISTRY
Other - Org Name:MAGNOLIA FAMILY DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:HEITZMANN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-707-5585
Mailing Address - Street 1:207 W JACKSON ST STE B
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-2355
Mailing Address - Country:US
Mailing Address - Phone:601-707-5585
Mailing Address - Fax:601-707-5586
Practice Address - Street 1:207 W JACKSON ST STE B
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-2355
Practice Address - Country:US
Practice Address - Phone:601-707-5585
Practice Address - Fax:601-707-5586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-09
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS355510122300000X
MS3491081223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty