Provider Demographics
NPI:1215959564
Name:MALLORY-MAY, HEATHER ANNE (DDS)
Entity type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:ANNE
Last Name:MALLORY-MAY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:HEATHER
Other - Middle Name:ANNE
Other - Last Name:MALLORY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:3340 BRETON CREEK CT SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49512-9088
Mailing Address - Country:US
Mailing Address - Phone:616-954-9899
Mailing Address - Fax:616-455-0815
Practice Address - Street 1:2351 COUNTRYWOOD DR SE
Practice Address - Street 2:SUITE A
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-5065
Practice Address - Country:US
Practice Address - Phone:616-455-0720
Practice Address - Fax:616-455-0815
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI150891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3142313Medicaid
MIJ150530OtherBLUE CROSS PIN