Provider Demographics
NPI:1841386331
Name:HEESCH, MARTY EVERETTE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARTY
Middle Name:EVERETTE
Last Name:HEESCH
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 1:1093 13TH STREET, SE
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28602
Mailing Address - Country:US
Mailing Address - Phone:828-324-7056
Mailing Address - Fax:828-324-9586
Practice Address - Street 1:1093 13TH STREET, SE
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602
Practice Address - Country:US
Practice Address - Phone:828-324-7056
Practice Address - Fax:828-324-9586
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC68291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1841386331Medicaid
NC56-2097170OtherEIN