Healthcare Provider Details

I. General information

NPI: 1750648564
Provider Name (Legal Business Name): HENTSCHER-JOHNSON ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2012
Last Update Date: 04/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E MILL ST
WATERLOO IL
62298-1519
US

IV. Provider business mailing address

200 E MILL ST
WATERLOO IL
62298-1519
US

V. Phone/Fax

Practice location:
  • Phone: 618-939-2900
  • Fax: 888-908-5295
Mailing address:
  • Phone: 618-939-2900
  • Fax: 888-908-5295

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.028038
License Number StateIL

VIII. Authorized Official

Name: DR. JODI KAY HENTSCHER-JOHNSON
Title or Position: DENTIST/ORTHODONTIST
Credential: D.M.D., M.S.
Phone: 618-939-2900