Provider Demographics
NPI:1720135478
Name:HEESEMAN, GARY JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:HEESEMAN
Suffix:JR
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 1:2200 RANDOLPH RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-1126
Mailing Address - Country:US
Mailing Address - Phone:704-334-4774
Mailing Address - Fax:704-334-4939
Practice Address - Street 1:2200 RANDOLPH RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1126
Practice Address - Country:US
Practice Address - Phone:704-334-4774
Practice Address - Fax:704-334-4939
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC29461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice