=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801996202
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KEVIN A HENNER,DMD,PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2006
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 163 HALF HOLLOW ROAD SUITE ONE
-----------------------------------------------------
City | DEER PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-667-2820
-----------------------------------------------------
Fax | 631-667-3133
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 163 HALF HOLLOW ROAD SUITE ONE
-----------------------------------------------------
City | DEER PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-667-2820
-----------------------------------------------------
Fax | 631-667-3133
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JKEVIN ANDREW HENNER
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 631-667-2820
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------