Provider Demographics
NPI:1629184866
Name:HENNEMAN, MICHAEL W (DDS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:W
Last Name:HENNEMAN
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 1:574 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-1682
Mailing Address - Country:US
Mailing Address - Phone:541-482-0541
Mailing Address - Fax:541-482-0542
Practice Address - Street 1:574 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-1682
Practice Address - Country:US
Practice Address - Phone:541-482-0541
Practice Address - Fax:541-482-0542
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD54661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice