Healthcare Provider Details

I. General information

NPI: 1093854408
Provider Name (Legal Business Name): SCOTT CARL HENNING DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14570 MONO WAY SUITE I
SONORA CA
95370
US

IV. Provider business mailing address

14570 MONO WAY SUITE I
SONORA CA
95370
US

V. Phone/Fax

Practice location:
  • Phone: 209-536-1954
  • Fax: 209-536-6554
Mailing address:
  • Phone: 209-536-1954
  • Fax: 209-536-6554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number36083
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: