Provider Demographics
NPI:1679562227
Name:HENNIS, PAUL (DDS)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:HENNIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:299 CANDLEWOOD PATH
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-8003
Mailing Address - Country:US
Mailing Address - Phone:718-723-4878
Mailing Address - Fax:718-341-4103
Practice Address - Street 1:23520 147TH AVE
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:NY
Practice Address - Zip Code:11422-3293
Practice Address - Country:US
Practice Address - Phone:718-723-4878
Practice Address - Fax:718-341-4103
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-17
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037149122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00739359Medicaid