MEDICARE: JACK W. HANEY, D.D.S., P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist
2	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1124598594
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACK W. HANEY, D.D.S., P.C.

Provider Business Mailing Address
First Line	:	9825 KENWOOD RD STE 200
Second Line	:
City	:	BLUE ASH
State	:	OH
Zip	:	45242-6252
Country	:	US
Telephone Number	:	513-808-4984
Fax Number	:	513-448-0511

Provider Business Practice Location Address
First Line	:	4527 FOREST PARK AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63108-2113
Country	:	US
Telephone Number	:	314-367-7200
Fax Number	:	314-367-0508

Authorized Official
Title or Position	:	DIRECTOR, PAYER RELATIONS
Name	:	TY JUSTICE
Credential	:
Telephone Number	:	513-808-4984

Provider Enumeration Date	:	11/28/2018
Last Update Date	:	11/28/2018

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