Provider Demographics
NPI:1225265309
Name:HENRY, MOLLY ANNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MOLLY
Middle Name:ANNE
Last Name:HENRY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16375 CRYSTAL HILLS CIR
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-5820
Mailing Address - Country:US
Mailing Address - Phone:612-599-8850
Mailing Address - Fax:
Practice Address - Street 1:1965 CLIFF LAKE RD
Practice Address - Street 2:SUITE #102
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-2590
Practice Address - Country:US
Practice Address - Phone:651-452-4828
Practice Address - Fax:651-452-4856
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND126761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice