Provider Demographics
NPI:1083846927
Name:HENNEBERG, RANDAL JAMES (DDS)
Entity Type:Individual
Prefix:
First Name:RANDAL
Middle Name:JAMES
Last Name:HENNEBERG
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 1:12701 E SPRAGUE AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99216-0727
Mailing Address - Country:US
Mailing Address - Phone:509-924-0055
Mailing Address - Fax:
Practice Address - Street 1:12701 E SPRAGUE AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-0727
Practice Address - Country:US
Practice Address - Phone:509-924-0055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-11
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4246122300000X
WADE601024001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist