Provider Demographics
NPI:1104387299
Name:HENRY, ROB (DMD)
Entity Type:Individual
Prefix:
First Name:ROB
Middle Name:
Last Name:HENRY
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 1:3602 ROLLING GREEN DR APT 237
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79606-7907
Mailing Address - Country:US
Mailing Address - Phone:325-696-8634
Mailing Address - Fax:
Practice Address - Street 1:697 LOUISIANA RD
Practice Address - Street 2:
Practice Address - City:DYESS AFB
Practice Address - State:TX
Practice Address - Zip Code:79607-1141
Practice Address - Country:US
Practice Address - Phone:325-696-8634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-29
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.032361122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist