Provider Demographics
NPI:1922620855
Name:HEINE, MADISON K (DMD)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:K
Last Name:HEINE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7926 PRESTON HWY STE 201
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40219-3848
Mailing Address - Country:US
Mailing Address - Phone:502-968-1412
Mailing Address - Fax:502-968-8797
Practice Address - Street 1:7926 PRESTON HWY STE 201
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-3848
Practice Address - Country:US
Practice Address - Phone:502-968-1412
Practice Address - Fax:502-968-8797
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-14
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120137071223G0001X
390200000X
KY110141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program