MEDICARE: DR. CJ HENLEY DMD

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	:	1558682245
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CJ HENLEY DMD

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	:

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	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2010
Last Update Date	:	08/08/2016

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