Provider Demographics
NPI:1124598594
Name:JACK W. HANEY, D.D.S., P.C.
Entity Type:Organization
Organization Name:JACK W. HANEY, D.D.S., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, PAYER RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:TY
Authorized Official - Middle Name:
Authorized Official - Last Name:JUSTICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-808-4984
Mailing Address - Street 1:9825 KENWOOD RD STE 200
Mailing Address - Street 2:
Mailing Address - City:BLUE ASH
Mailing Address - State:OH
Mailing Address - Zip Code:45242-6252
Mailing Address - Country:US
Mailing Address - Phone:513-808-4984
Mailing Address - Fax:513-448-0511
Practice Address - Street 1:4527 FOREST PARK AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2113
Practice Address - Country:US
Practice Address - Phone:314-367-7200
Practice Address - Fax:314-367-0508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-28
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty