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
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X  Y193200000X MULTI-SPECIALTY GROUPDental ProvidersDentist 

ID Information
IDTypeStateIssuerDescription
6872601IDBLUE CROSSOTHER
00001001243801IDBLUE SHIELDOTHER


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