MEDICARE: C.J. HENLEY, DMD, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DN18997	FL

General Provider Information

NPI Number	:	1487196218
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	C.J. HENLEY, DMD, PA

Provider Business Mailing Address
First Line	:	3675 HENDRICKS AVE
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-5360
Country	:	US
Telephone Number	:	904-398-1549
Fax Number	:	904-398-1551

Provider Business Practice Location Address
First Line	:	3675 HENDRICKS AVE
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-5360
Country	:	US
Telephone Number	:	904-398-1549
Fax Number	:	904-398-1551

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CHRISTOPHER JON HENLEY
Credential	:	DMD
Telephone Number	:	904-398-1549

Provider Enumeration Date	:	11/10/2016
Last Update Date	:	11/10/2016

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