Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 6942 | KY |
Y | 1223S0112X | Oral and Maxillofacial Surgeon | 6942 | KY |
N | 204E00000X | Oral & Maxillofacial Surgeon | 6942 | KY |
NPI | 1083787386 |
---|---|
Provider Name | Dr. Brian Tory Heine |
First Address | Paducah, KY 42003-8043 |
Second Address | Paducah, KY 42003-8043 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/11/2006 |
Last Update Date | 14/10/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U84875 | (02) |