Provider Demographics
NPI:1093206815
Name:MA, HENRY (DMD)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:
Last Name:MA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1214 MIRABEAU LN
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95132-2885
Mailing Address - Country:US
Mailing Address - Phone:408-646-0220
Mailing Address - Fax:
Practice Address - Street 1:11040 BOLLINGER CANYON RD
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94582-4969
Practice Address - Country:US
Practice Address - Phone:408-646-0220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1024711223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics