Provider Demographics
NPI:1629168349
Name:HENSLEY, JONATHAN SHANE (DMD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:SHANE
Last Name:HENSLEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 TRIVETTE DR STE 103
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41501-1275
Mailing Address - Country:US
Mailing Address - Phone:606-433-1488
Mailing Address - Fax:606-433-1487
Practice Address - Street 1:126 TRIVETTE DR STE 103
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-1275
Practice Address - Country:US
Practice Address - Phone:606-433-1488
Practice Address - Fax:606-433-1487
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7602122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60000353Medicaid