Provider Demographics
NPI: | 1134491103 |
---|---|
Name: | DR STEPHEN R. HENRY, DDS PC |
Entity Type: | Organization |
Organization Name: | DR STEPHEN R. HENRY, DDS PC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | DENTIST |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | STEPHEN |
Authorized Official - Middle Name: | R |
Authorized Official - Last Name: | HENRY |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DDS |
Authorized Official - Phone: | 586-781-6700 |
Mailing Address - Street 1: | PO BOX 660 |
Mailing Address - Street 2: | |
Mailing Address - City: | WASHINGTON TWP |
Mailing Address - State: | MI |
Mailing Address - Zip Code: | 48094-0660 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 586-781-6700 |
Mailing Address - Fax: | 586-781-6819 |
Practice Address - Street 1: | 57911 VAN DYKE RD |
Practice Address - Street 2: | SUITE B |
Practice Address - City: | WASHINGTON TWP |
Practice Address - State: | MI |
Practice Address - Zip Code: | 48094-2763 |
Practice Address - Country: | US |
Practice Address - Phone: | 586-781-6700 |
Practice Address - Fax: | 586-781-6819 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2012-02-06 |
Last Update Date: | 2012-02-06 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MI | 16538 | 122300000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 122300000X | Dental Providers | Dentist | Group - Single Specialty |