Provider Demographics
NPI:1720204332
Name:HEINER, STAN R (DDS)
Entity Type:Individual
Prefix:DR
First Name:STAN
Middle Name:R
Last Name:HEINER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 OAKDALE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-3306
Mailing Address - Country:US
Mailing Address - Phone:209-577-3792
Mailing Address - Fax:209-577-6951
Practice Address - Street 1:1540 OAKDALE RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-3306
Practice Address - Country:US
Practice Address - Phone:209-577-3792
Practice Address - Fax:209-577-6951
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA259011223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics