Organization
JACK W. HANEY, D.D.S., P.C.
Active
Other names
Forest Park Dental
Organization subpart
No
Provider details
NPI number
Authorized official
TY JUSTICE (DIRECTOR, PAYER RELATIONS)
(513) 808-4984
Entity
Organization
Contact information
Practice address
4527 FOREST PARK AVE, SAINT LOUIS, MO 63108-2113
(314) 367-7200
(314) 367-0508
Mailing address
9825 KENWOOD RD STE 200, BLUE ASH, OH 45242-6252
(513) 808-4984
(513) 448-0511
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
—
—
1223G0001X
General Practice Dentistry
Primary
—
—
Other
Enumeration date
11/28/2018
Last updated
11/28/2018
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