Provider Demographics
NPI:1730863275
Name:HENTHORN, JEFFERSON TYLER (DDS)
Entity type:Individual
Prefix:DR
First Name:JEFFERSON
Middle Name:TYLER
Last Name:HENTHORN
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 1:1403 N LOOP 336 W STE C
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-3672
Mailing Address - Country:US
Mailing Address - Phone:936-242-4031
Mailing Address - Fax:
Practice Address - Street 1:1403 N LOOP 336 W STE C
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-3672
Practice Address - Country:US
Practice Address - Phone:936-242-4031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39709122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist