MEDICARE: DR. JEFFREY J HENNEBERG DDS

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	1223G0001X	General Practice Dentistry	DE00010235	WA

General Provider Information

NPI Number	:	1710906631
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY J HENNEBERG DDS

Provider Business Mailing Address
First Line	:	100 N MULLAN RD
Second Line	:	SUITE #204
City	:	SPOKANE VALLEY
State	:	WA
Zip	:	99206-6848
Country	:	US
Telephone Number	:	509-928-8400
Fax Number	:	509-928-1845

Provider Business Practice Location Address
First Line	:	100 N MULLAN RD
Second Line	:	SUITE #204
City	:	SPOKANE VALLEY
State	:	WA
Zip	:	99206-6848
Country	:	US
Telephone Number	:	509-928-8400
Fax Number	:	509-928-1845

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

Provider Enumeration Date	:	07/19/2006
Last Update Date	:	07/08/2007

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