Provider Demographics
NPI:1710906631
Name:HENNEBERG, JEFFREY J (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:J
Last Name:HENNEBERG
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 1:100 N MULLAN RD
Mailing Address - Street 2:SUITE #204
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99206-6848
Mailing Address - Country:US
Mailing Address - Phone:509-928-8400
Mailing Address - Fax:509-928-1845
Practice Address - Street 1:100 N MULLAN RD
Practice Address - Street 2:SUITE #204
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-6848
Practice Address - Country:US
Practice Address - Phone:509-928-8400
Practice Address - Fax:509-928-1845
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000102351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice