Provider Demographics
NPI:1265473714
Name:HENDERSON, GARY STARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:STARK
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 1:622 7TH ST
Mailing Address - Street 2:
Mailing Address - City:PAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74058-2541
Mailing Address - Country:US
Mailing Address - Phone:918-762-2600
Mailing Address - Fax:918-762-2600
Practice Address - Street 1:622 7TH ST
Practice Address - Street 2:
Practice Address - City:PAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74058-2541
Practice Address - Country:US
Practice Address - Phone:918-762-2600
Practice Address - Fax:918-762-2600
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK37961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice