Provider Demographics
NPI:1568578508
Name:HENRY, PELHAM H JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:PELHAM
Middle Name:H
Last Name:HENRY
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 522
Mailing Address - Street 2:1013 MEDICAL CENTER PKWY
Mailing Address - City:SELMA
Mailing Address - State:AL
Mailing Address - Zip Code:36702-0522
Mailing Address - Country:US
Mailing Address - Phone:334-874-7670
Mailing Address - Fax:334-875-7942
Practice Address - Street 1:1013 MEDICAL CENTER PKWY
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:AL
Practice Address - Zip Code:36701-0522
Practice Address - Country:US
Practice Address - Phone:334-874-7670
Practice Address - Fax:334-875-7942
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALZ86Z1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
T68720Medicare UPIN