Provider Demographics
NPI:1780799072
Name:HEINECKE, PHILIP N (DDS)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:N
Last Name:HEINECKE
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 1:103 BELL AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34601-2603
Mailing Address - Country:US
Mailing Address - Phone:352-796-3380
Mailing Address - Fax:352-796-0937
Practice Address - Street 1:103 BELL AVE
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-2603
Practice Address - Country:US
Practice Address - Phone:352-796-3380
Practice Address - Fax:352-796-0937
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN110901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice