=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215099437
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIAN L HENNINGSEN DDS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1600 SOUTHWEST BLVD # B
-----------------------------------------------------
City | JEFFERSON CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65109-2434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-635-4852
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1600 SOUTHWEST BLVD # B
-----------------------------------------------------
City | JEFFERSON CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65109-2434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-635-4852
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BRIAN L HENNINGSEN
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 573-635-4852
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 013482
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------