Provider Demographics
NPI:1417101981
Name:HERITAGE DENTAL, P.C.
Entity Type:Organization
Organization Name:HERITAGE DENTAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:BRADLEY
Authorized Official - Last Name:MCKINNEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:205-625-3865
Mailing Address - Street 1:308 6TH ST S
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ONEONTA
Mailing Address - State:AL
Mailing Address - Zip Code:35121-1846
Mailing Address - Country:US
Mailing Address - Phone:205-625-3865
Mailing Address - Fax:205-274-0384
Practice Address - Street 1:308 6TH ST S
Practice Address - Street 2:SUITE 101
Practice Address - City:ONEONTA
Practice Address - State:AL
Practice Address - Zip Code:35121-1846
Practice Address - Country:US
Practice Address - Phone:205-625-3865
Practice Address - Fax:205-274-0384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-11
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL56171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty