Provider Demographics
NPI:1609863646
Name:HANEY, JERRY L (DDS)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:L
Last Name:HANEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:MO
Mailing Address - Zip Code:64076-1152
Mailing Address - Country:US
Mailing Address - Phone:816-633-5393
Mailing Address - Fax:816-633-5395
Practice Address - Street 1:404 N 4TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:MO
Practice Address - Zip Code:64076-1152
Practice Address - Country:US
Practice Address - Phone:816-633-5393
Practice Address - Fax:816-633-5395
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO13680122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist