Provider Demographics
NPI:1558432666
Name:HENNESSEY, THEODORE MARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:MARK
Last Name:HENNESSEY
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 1:19715 SCRIBER LAKE RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-6165
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:181 S 333RD ST
Practice Address - Street 2:SUITE C-100
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-7363
Practice Address - Country:US
Practice Address - Phone:253-661-6381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-11
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000105891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice