Provider Demographics
NPI:1033158993
Name:HENNINGSEN, BRIAN LEROY (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:LEROY
Last Name:HENNINGSEN
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 1:1600 B SOUTHWEST BLVD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109
Mailing Address - Country:US
Mailing Address - Phone:573-635-4852
Mailing Address - Fax:573-635-1167
Practice Address - Street 1:1600 B SOUTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109
Practice Address - Country:US
Practice Address - Phone:573-635-4852
Practice Address - Fax:573-635-1167
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0134821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice