Provider Demographics
NPI:1194459594
Name:HEINS, SHANTELL (DDS)
Entity type:Individual
Prefix:
First Name:SHANTELL
Middle Name:
Last Name:HEINS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 1ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413
Mailing Address - Country:US
Mailing Address - Phone:122-555-5696
Mailing Address - Fax:
Practice Address - Street 1:411 1ST AVE NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413
Practice Address - Country:US
Practice Address - Phone:612-255-5569
Practice Address - Fax:612-255-5560
Is Sole Proprietor?:No
Enumeration Date:2022-07-12
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND14796122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist