Basic Information
Provider Information
NPI: 1033558234
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: HENRY
FirstName: DAVID
MiddleName: EDMOND
NamePrefix: DR.
NameSuffix:  
Credential: D.D.S.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 605 E CENTER ST
Address2:  
City: COLLINSVILLE
State: OK
PostalCode: 740213640
CountryCode: US
TelephoneNumber: 9188455505
FaxNumber:  
Practice Location
Address1: 27371 S 4410 RD
Address2:  
City: VINITA
State: OK
PostalCode: 743017953
CountryCode: US
TelephoneNumber: 9182534800
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/20/2013
LastUpdateDate: 06/20/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1223G0001X6531OKY Dental ProvidersDentistGeneral Practice

No ID Information.


Home