Provider Demographics
NPI:1073692836
Name:HENRY, WILLIAM DAVID (DMD, PT)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:DAVID
Last Name:HENRY
Suffix:
Gender:M
Credentials:DMD, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5935 HIGHWAY 18 W
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39209-9625
Mailing Address - Country:US
Mailing Address - Phone:601-922-7028
Mailing Address - Fax:601-922-9005
Practice Address - Street 1:5935 HIGHWAY 18 W
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39209-9625
Practice Address - Country:US
Practice Address - Phone:601-922-7028
Practice Address - Fax:601-922-9005
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT 2975225100000X
MS3496-091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS7416031OtherAETNA #
MS000050976OtherBCBS
MS00121341Medicaid
MS25-4533Medicare ID - Type Unspecified1/1/2000