Provider Demographics
NPI:1073672952
Name:HENDERSON, MARLON
Entity Type:Individual
Prefix:
First Name:MARLON
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 INTERNATIONAL PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75081-6612
Mailing Address - Country:US
Mailing Address - Phone:972-572-0100
Mailing Address - Fax:
Practice Address - Street 1:3306 W CAMP WISDOM RD
Practice Address - Street 2:SUITE 100
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-2596
Practice Address - Country:US
Practice Address - Phone:972-572-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX195771223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics