Provider Demographics
NPI:1376562082
Name:HENDERSON, MARK REAGAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:REAGAN
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 1:5700 ARNOLD ST
Mailing Address - Street 2:
Mailing Address - City:TINKER AFB
Mailing Address - State:OK
Mailing Address - Zip Code:73145-8105
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5700 ARNOLD ST
Practice Address - Street 2:
Practice Address - City:TINKER AFB
Practice Address - State:OK
Practice Address - Zip Code:73145-8105
Practice Address - Country:US
Practice Address - Phone:405-736-2113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX139861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice