Provider Demographics
NPI:1417188459
Name:HENDERSON, BRIAN T (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:T
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 1:1419 SUPERIOR AVE
Mailing Address - Street 2:SUITE #6
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-2723
Mailing Address - Country:US
Mailing Address - Phone:949-646-4801
Mailing Address - Fax:
Practice Address - Street 1:1419 SUPERIOR AVE
Practice Address - Street 2:SUITE #6
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-2723
Practice Address - Country:US
Practice Address - Phone:949-646-4801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-06
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA337761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice