Provider Demographics
NPI:1174853683
Name:HENNESSEY, ROGER F (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:F
Last Name:HENNESSEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7174 SANTA TERESA BLVD
Mailing Address - Street 2:A5
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95139-1350
Mailing Address - Country:US
Mailing Address - Phone:408-578-0252
Mailing Address - Fax:
Practice Address - Street 1:7174 SANTA TERESA BLVD
Practice Address - Street 2:A5
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95139-1350
Practice Address - Country:US
Practice Address - Phone:408-578-0252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-05
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55813122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist