Provider Demographics
NPI:1417023144
Name:HENNIG, THEODORE B (DDS MS)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:B
Last Name:HENNIG
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4350 FASHION SQUARE BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-1249
Mailing Address - Country:US
Mailing Address - Phone:989-799-7128
Mailing Address - Fax:989-799-3895
Practice Address - Street 1:4350 FASHION SQUARE BOULEVARD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-1249
Practice Address - Country:US
Practice Address - Phone:989-799-7128
Practice Address - Fax:989-799-3895
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010147161223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Not Answered204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOG361000OtherBLUE CARE NETWORK
MIOG361000OtherBCBS OF MI
MIOG361000OtherBLUE CARE NETWORK
MIG36100001Medicare ID - Type Unspecified