Provider Demographics
NPI:1295999068
Name:HEIDNER, GARY MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:MICHAEL
Last Name:HEIDNER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
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Mailing Address - Street 1:4248 CANDLEBERRY AVE
Mailing Address - Street 2:
Mailing Address - City:SEAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90740
Mailing Address - Country:US
Mailing Address - Phone:562-881-9243
Mailing Address - Fax:714-260-0177
Practice Address - Street 1:12752 GARDEN GROVE BLVD
Practice Address - Street 2:#200
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-1923
Practice Address - Country:US
Practice Address - Phone:714-636-2595
Practice Address - Fax:714-260-0177
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-10
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA236141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice