Provider Demographics
NPI:1558682245
Name:HENLEY, CJ (DMD)
Entity Type:Individual
Prefix:DR
First Name:CJ
Middle Name:
Last Name:HENLEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:CHRISTOPHER
Other - Middle Name:
Other - Last Name:HENLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3675 HENDRICKS AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-5360
Mailing Address - Country:US
Mailing Address - Phone:904-398-1549
Mailing Address - Fax:
Practice Address - Street 1:3675 HENDRICKS AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-5360
Practice Address - Country:US
Practice Address - Phone:904-398-1549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-16
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN18997122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist