Provider Demographics
NPI:1700103066
Name:HEILIG, MARVIN RONALD (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:RONALD
Last Name:HEILIG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 CORPORATE DR STE 101
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-5426
Mailing Address - Country:US
Mailing Address - Phone:859-223-3826
Mailing Address - Fax:859-223-1642
Practice Address - Street 1:860 CORPORATE DR STE 101
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-5426
Practice Address - Country:US
Practice Address - Phone:859-223-3826
Practice Address - Fax:859-223-1643
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-27
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5192122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist