Provider Demographics
NPI:1578079828
Name:HENDERSON, LATISHA DEIDRA (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:LATISHA
Middle Name:DEIDRA
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 ALTER ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-5406
Mailing Address - Country:US
Mailing Address - Phone:856-534-4326
Mailing Address - Fax:
Practice Address - Street 1:1000 LINCOLN DR E
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-1566
Practice Address - Country:US
Practice Address - Phone:877-422-6257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-22
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI026970001223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics