Provider Demographics
NPI:1215099437
Name:BRIAN L HENNINGSEN DDS PC
Entity type:Organization
Organization Name:BRIAN L HENNINGSEN DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:HENNINGSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:573-635-4852
Mailing Address - Street 1:1600 SOUTHWEST BLVD # B
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-2434
Mailing Address - Country:US
Mailing Address - Phone:573-635-4852
Mailing Address - Fax:
Practice Address - Street 1:1600 SOUTHWEST BLVD # B
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-2434
Practice Address - Country:US
Practice Address - Phone:573-635-4852
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO013482122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty