Provider Demographics
NPI:1467639872
Name:L. M. HENDERSON D.M.D.,P.A.
Entity Type:Organization
Organization Name:L. M. HENDERSON D.M.D.,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:M
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD,PA
Authorized Official - Phone:501-835-0444
Mailing Address - Street 1:3006 E KIEHL AVE
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72120-3228
Mailing Address - Country:US
Mailing Address - Phone:501-835-0444
Mailing Address - Fax:501-835-8730
Practice Address - Street 1:3006 E KIEHL AVE
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:AR
Practice Address - Zip Code:72120-3228
Practice Address - Country:US
Practice Address - Phone:501-835-0444
Practice Address - Fax:501-835-8730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-28
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR22091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5C125OtherBCBS