Provider Demographics
NPI:1659468569
Name:HEISE, GREGORY JAMES (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:JAMES
Last Name:HEISE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2525 K ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-5114
Mailing Address - Country:US
Mailing Address - Phone:916-442-1882
Mailing Address - Fax:916-442-3039
Practice Address - Street 1:2525 K ST
Practice Address - Street 2:SUITE 101
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5114
Practice Address - Country:US
Practice Address - Phone:916-442-1882
Practice Address - Fax:916-442-3039
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA284501223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU44323Medicare ID - Type UnspecifiedMEDICARE