Provider Demographics
NPI:1245212273
Name:STALEY-HENNE, JEFFREY DAVID (DMD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:DAVID
Last Name:STALEY-HENNE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:JEFFREY
Other - Middle Name:DAVID
Other - Last Name:HENNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:1281 N 2200TH ST
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:IL
Mailing Address - Zip Code:61944-6075
Mailing Address - Country:US
Mailing Address - Phone:217-275-3587
Mailing Address - Fax:
Practice Address - Street 1:701 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:IL
Practice Address - Zip Code:61944-2329
Practice Address - Country:US
Practice Address - Phone:217-463-4155
Practice Address - Fax:217-463-4156
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9179723Medicaid