Provider Demographics
NPI:1912054917
Name:VICTORINE, HEATHER
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:
Last Name:VICTORINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:259 ARROWHEAD BLVD
Mailing Address - Street 2:SUITE B-2
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-1167
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:175 COUNTRY CLUB DR BLDG 300B
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7388
Practice Address - Country:US
Practice Address - Phone:678-565-9452
Practice Address - Fax:678-565-9484
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013227122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA175566289AMedicaid