Provider Demographics
NPI:1093987216
Name:HENDERSON, JASON DAVID (DDS)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:DAVID
Last Name:HENDERSON
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 1:8179 CAZENOVIA RD
Mailing Address - Street 2:
Mailing Address - City:MANLIUS
Mailing Address - State:NY
Mailing Address - Zip Code:13104-9778
Mailing Address - Country:US
Mailing Address - Phone:315-682-2466
Mailing Address - Fax:315-682-3179
Practice Address - Street 1:8179 CAZENOVIA RD.
Practice Address - Street 2:
Practice Address - City:MANLIUS
Practice Address - State:NY
Practice Address - Zip Code:13104
Practice Address - Country:US
Practice Address - Phone:315-682-2466
Practice Address - Fax:315-682-3179
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-27
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0544881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1316096340Medicaid