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General NPI Number Information
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NPI Number | 1558432666
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Entity Type | Individual
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Provider Name | THEODORE MARK HENNESSEY DDS
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Gender | Male
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Dates
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Enumeration Date | 11/11/2006
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Last Update Date | 06/21/2012
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Provider Practice Location Address
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Address Line | 181 S 333RD ST SUITE C-100
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City | FEDERAL WAY
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State | WA
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Zip | 98003-7363
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Country | US
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Telephone | 253-661-6381
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Fax |
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Provider Business Mailing Address
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Address Line | 19715 SCRIBER LAKE RD SUITE C
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City | LYNNWOOD
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State | WA
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Zip | 98036-6165
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DE00010589
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License Number State | WA
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