Provider Demographics
NPI:1275543092
Name:HENDERSON, ROBERT E (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:E
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 1:824 E REDD RD
Mailing Address - Street 2:STE. 1-B
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-7262
Mailing Address - Country:US
Mailing Address - Phone:915-833-0303
Mailing Address - Fax:
Practice Address - Street 1:824 E REDD RD
Practice Address - Street 2:STE. 1-B
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-7262
Practice Address - Country:US
Practice Address - Phone:915-833-0303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDENT08841Medicaid