Provider Demographics
NPI:1487196218
Name:C.J. HENLEY, DMD, PA
Entity type:Organization
Organization Name:C.J. HENLEY, DMD, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:JON
Authorized Official - Last Name:HENLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:904-398-1549
Mailing Address - Street 1:3675 HENDRICKS AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-5360
Mailing Address - Country:US
Mailing Address - Phone:904-398-1549
Mailing Address - Fax:904-398-1551
Practice Address - Street 1:3675 HENDRICKS AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-5360
Practice Address - Country:US
Practice Address - Phone:904-398-1549
Practice Address - Fax:904-398-1551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-10
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN18997122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty