Provider Demographics
NPI:1619243482
Name:HORNBERGER, JOHN CHARLES (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CHARLES
Last Name:HORNBERGER
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 1:4616 S US HIGHWAY 75 # 201
Mailing Address - Street 2:
Mailing Address - City:DENISON
Mailing Address - State:TX
Mailing Address - Zip Code:75020-4582
Mailing Address - Country:US
Mailing Address - Phone:903-416-8585
Mailing Address - Fax:903-416-8484
Practice Address - Street 1:4616 S US HIGHWAY 75 # 201
Practice Address - Street 2:
Practice Address - City:DENISON
Practice Address - State:TX
Practice Address - Zip Code:75020
Practice Address - Country:US
Practice Address - Phone:903-416-8585
Practice Address - Fax:903-416-8484
Is Sole Proprietor?:No
Enumeration Date:2012-03-27
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY97151223S0112X, 204E00000X
TX28622204E00000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100182880Medicaid
KY7100182980Medicaid