Provider Demographics
NPI:1780694968
Name:HENN, GEREMY LUCAS (DDS, MSD)
Entity type:Individual
Prefix:
First Name:GEREMY
Middle Name:LUCAS
Last Name:HENN
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3405 SASSE WAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-8514
Mailing Address - Country:US
Mailing Address - Phone:317-331-8007
Mailing Address - Fax:
Practice Address - Street 1:4816 GREENWOOD RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40258-3634
Practice Address - Country:US
Practice Address - Phone:502-935-7212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120104081223G0001X
KY88311223X0400X
IN12010408A1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200508180Medicaid