Provider Demographics
NPI:1376562637
Name:HENSHAW, AUBREY J III (DDS)
Entity Type:Individual
Prefix:
First Name:AUBREY
Middle Name:J
Last Name:HENSHAW
Suffix:III
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:PO BOX 708
Mailing Address - Street 2:
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955-0708
Mailing Address - Country:US
Mailing Address - Phone:918-775-4431
Mailing Address - Fax:918-775-4432
Practice Address - Street 1:611 W RUTH AVE
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-6866
Practice Address - Country:US
Practice Address - Phone:918-775-4431
Practice Address - Fax:918-775-4432
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK752271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100132280BMedicaid