1558432666 NPI number — DR. THEODORE MARK HENNESSEY DDS

Table of content: DR. THEODORE MARK HENNESSEY DDS (NPI 1558432666)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558432666 NPI number — DR. THEODORE MARK HENNESSEY DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENNESSEY
Provider First Name:
THEODORE
Provider Middle Name:
MARK
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558432666
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/21/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19715 SCRIBER LAKE RD
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
LYNNWOOD
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98036-6165
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
181 S 333RD ST
Provider Second Line Business Practice Location Address:
SUITE C-100
Provider Business Practice Location Address City Name:
FEDERAL WAY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98003-7363
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-661-6381
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DE00010589 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com