Basic Information
| Provider Information | |||||||||
| NPI: | 1639260516 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENLEY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1625 DAVID RAINES RD | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711075899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184252252 | ||||||||
| FaxNumber: | 3182273357 | ||||||||
| Practice Location | |||||||||
| Address1: | 1625 DAVID RAINES RD | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711075899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184252252 | ||||||||
| FaxNumber: | 3182273357 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 4967 | LA | Y | Dental Providers | Dentist |
No ID Information.