Provider Demographics
NPI:1033558234
Name:HENRY, DAVID EDMOND (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:EDMOND
Last Name:HENRY
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 1:605 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74021-3640
Mailing Address - Country:US
Mailing Address - Phone:918-845-5505
Mailing Address - Fax:
Practice Address - Street 1:27371 S 4410 RD
Practice Address - Street 2:
Practice Address - City:VINITA
Practice Address - State:OK
Practice Address - Zip Code:74301-7953
Practice Address - Country:US
Practice Address - Phone:918-253-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-20
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK65311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice