Provider Demographics
NPI:1497206049
Name:BRIAN L HENNINGSEN DDS PC
Entity Type:Organization
Organization Name:BRIAN L HENNINGSEN DDS PC
Other - Org Name:ADMIRE YOUR SMILE PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:HENNINGSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:573-635-4852
Mailing Address - Street 1:1600B SOUTHWEST BLVD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-2434
Mailing Address - Country:US
Mailing Address - Phone:573-635-4852
Mailing Address - Fax:573-635-1167
Practice Address - Street 1:1600B SOUTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-2434
Practice Address - Country:US
Practice Address - Phone:573-635-4852
Practice Address - Fax:573-635-1167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0134821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty