Basic Information
Provider Information | |||||||||
NPI: | 1760592869 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | JEFFREY L HENKEN DDS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1020 E LOCUST | ||||||||
Address2: |   | ||||||||
City: | EMMETT | ||||||||
State: | ID | ||||||||
PostalCode: | 83617 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2083655064 | ||||||||
FaxNumber: | 2083654235 | ||||||||
Practice Location | |||||||||
Address1: | 1020 E LOCUST | ||||||||
Address2: |   | ||||||||
City: | EMMETT | ||||||||
State: | ID | ||||||||
PostalCode: | 83617 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2083655064 | ||||||||
FaxNumber: | 2083654235 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/30/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HENKEN | ||||||||
AuthorizedOfficialFirstName: | JEFFREY | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | DENTIST OWNER | ||||||||
AuthorizedOfficialTelephone: | 2083655064 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DDS | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |   |
ID Information
ID | Type | State | Issuer | Description | 68726 | 01 | ID | BLUE CROSS | OTHER | 000010012438 | 01 | ID | BLUE SHIELD | OTHER |