Provider Demographics
NPI:1821051533
Name:HEACOCK, JODI (DDS)
Entity Type:Individual
Prefix:DR
First Name:JODI
Middle Name:
Last Name:HEACOCK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7006 S CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-5423
Mailing Address - Country:US
Mailing Address - Phone:602-276-1029
Mailing Address - Fax:602-276-1838
Practice Address - Street 1:7006 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-5423
Practice Address - Country:US
Practice Address - Phone:602-276-1029
Practice Address - Fax:602-276-1838
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD54051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ578106OtherAHCCCS