Provider Demographics
NPI:1174623573
Name:HENNER, KEVIN ANDREW (DMD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:ANDREW
Last Name:HENNER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 HALF HOLLOW RD.
Mailing Address - Street 2:SUITE ONE
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729
Mailing Address - Country:US
Mailing Address - Phone:631-667-2820
Mailing Address - Fax:631-667-3133
Practice Address - Street 1:163 HALF HOLLOW RD.
Practice Address - Street 2:SUITE ONE
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729
Practice Address - Country:US
Practice Address - Phone:631-667-2820
Practice Address - Fax:631-667-3133
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0430201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice