Provider Demographics
NPI:1508996240
Name:HENDERLIGHT, PHILIP E JR (DMD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:E
Last Name:HENDERLIGHT
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1507 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701-1932
Mailing Address - Country:US
Mailing Address - Phone:606-523-1110
Mailing Address - Fax:
Practice Address - Street 1:1507 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-1932
Practice Address - Country:US
Practice Address - Phone:606-523-1110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY54141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60054145Medicaid