Provider Demographics
NPI:1316784606
Name:MCHENRY, JACOB (LD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:MCHENRY
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8707 JACKRABBIT LN STE C
Mailing Address - Street 2:
Mailing Address - City:BELGRADE
Mailing Address - State:MT
Mailing Address - Zip Code:59714-8994
Mailing Address - Country:US
Mailing Address - Phone:406-813-8551
Mailing Address - Fax:406-813-8519
Practice Address - Street 1:8707 JACKRABBIT LN STE C
Practice Address - Street 2:
Practice Address - City:BELGRADE
Practice Address - State:MT
Practice Address - Zip Code:59714-8994
Practice Address - Country:US
Practice Address - Phone:406-813-8551
Practice Address - Fax:406-813-8519
Is Sole Proprietor?:No
Enumeration Date:2024-07-12
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT28460122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist