Basic Information
| Provider Information | |||||||||
| NPI: | 1477902070 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENNIS | ||||||||
| FirstName: | JOSHUA | ||||||||
| MiddleName: | ALLEN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | X2 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1631 WETZEL AVE | ||||||||
| Address2: | BLDG 815 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809134095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195265537 | ||||||||
| FaxNumber: | 7195242843 | ||||||||
| Practice Location | |||||||||
| Address1: | 4TH & INNER LOOP ROAD | ||||||||
| Address2: | BLDG 171 | ||||||||
| City: | FORT IRWIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195265537 | ||||||||
| FaxNumber: | 7195242843 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2016 | ||||||||
| LastUpdateDate: | 06/06/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 126800000X | Y | Dental Providers | Dental Assistant |
No ID Information.