Provider Demographics
NPI:1891711610
Name:HEINBACH, MARVIN (DDS)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:
Last Name:HEINBACH
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 1:10 E 9TH ST
Mailing Address - Street 2:SUITE C/D
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66044-2621
Mailing Address - Country:US
Mailing Address - Phone:785-749-2525
Mailing Address - Fax:785-749-9524
Practice Address - Street 1:10 E 9TH ST
Practice Address - Street 2:SUITE C/D
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66044-2621
Practice Address - Country:US
Practice Address - Phone:785-749-2525
Practice Address - Fax:785-749-9524
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS602011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1494001OtherUNITED CONCORDIA