Provider Demographics
NPI:1679877146
Name:JEFFREY J HENNEBERG, DDS
Entity type:Organization
Organization Name:JEFFREY J HENNEBERG, DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:HENNEBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:509-928-8400
Mailing Address - Street 1:100 N MULLAN RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99206-6859
Mailing Address - Country:US
Mailing Address - Phone:509-928-8400
Mailing Address - Fax:509-928-1845
Practice Address - Street 1:5901 N MAYFAIR ST
Practice Address - Street 2:SUITE 201
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-5096
Practice Address - Country:US
Practice Address - Phone:509-928-8400
Practice Address - Fax:509-928-1845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-27
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty