Provider Demographics
NPI:1699192708
Name:HEINLE, AMY L (RDH)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:L
Last Name:HEINLE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 ARBOR AVE
Mailing Address - Street 2:
Mailing Address - City:SUGAR GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60554-5403
Mailing Address - Country:US
Mailing Address - Phone:309-236-1586
Mailing Address - Fax:
Practice Address - Street 1:111 ARBOR AVE
Practice Address - Street 2:
Practice Address - City:SUGAR GROVE
Practice Address - State:IL
Practice Address - Zip Code:60554-5403
Practice Address - Country:US
Practice Address - Phone:309-236-1586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-26
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL020005855124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist