Provider Demographics
NPI:1093821647
Name:HENLEY, STEPHANIE REEDER (MD, DMD)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:REEDER
Last Name:HENLEY
Suffix:
Gender:F
Credentials:MD, DMD
Other - Prefix:DR
Other - First Name:STEPHANIE
Other - Middle Name:LYNN
Other - Last Name:REEDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD,DMD
Mailing Address - Street 1:4100 SOUTHPOINT DR E STE 5
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-8710
Mailing Address - Country:US
Mailing Address - Phone:904-281-2225
Mailing Address - Fax:
Practice Address - Street 1:4100 SOUTHPOINT DR E STE 5
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-8710
Practice Address - Country:US
Practice Address - Phone:904-565-1505
Practice Address - Fax:904-565-1506
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 164251223G0001X, 204E00000X
FLDN164251223S0112X
FLME113042204E00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223G0001XDental ProvidersDentistGeneral Practice
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery