Provider Demographics
NPI:1356459671
Name:HEENAN, MARK JOSEPH (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JOSEPH
Last Name:HEENAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 MIAMI ST
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43605-2278
Mailing Address - Country:US
Mailing Address - Phone:419-693-4712
Mailing Address - Fax:419-693-4495
Practice Address - Street 1:725 MIAMI ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43605-2278
Practice Address - Country:US
Practice Address - Phone:419-693-4712
Practice Address - Fax:419-693-4495
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-27
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH170291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH04944OtherPARAMOUNT
OH2618984Medicaid