Provider Demographics
NPI:1750648564
Name:HENTSCHER-JOHNSON ORTHODONTICS
Entity Type:Organization
Organization Name:HENTSCHER-JOHNSON ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JODI
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:HENTSCHER-JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:618-939-2900
Mailing Address - Street 1:200 E MILL ST
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-1519
Mailing Address - Country:US
Mailing Address - Phone:618-939-2900
Mailing Address - Fax:888-908-5295
Practice Address - Street 1:200 E MILL ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298-1519
Practice Address - Country:US
Practice Address - Phone:618-939-2900
Practice Address - Fax:888-908-5295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-18
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.028038122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1942577234OtherTYPE 1 NPI