Provider Demographics
NPI:1801266549
Name:JEFFREY J. HENNEBERG, D.D.S., P.C.
Entity type:Organization
Organization Name:JEFFREY J. HENNEBERG, D.D.S., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:HENNEBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:509-928-8400
Mailing Address - Street 1:1215 N MCDONALD RD STE 203
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99216-1557
Mailing Address - Country:US
Mailing Address - Phone:509-928-8400
Mailing Address - Fax:
Practice Address - Street 1:1215 N MCDONALD RD STE 203
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-1557
Practice Address - Country:US
Practice Address - Phone:509-928-8400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-06
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602629210332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment