Provider Demographics
NPI:1578989083
Name:HENDERSON, MICHAEL EDWIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:EDWIN
Last Name:HENDERSON
Suffix:
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 1:128 W CHEROKEE ST
Mailing Address - Street 2:
Mailing Address - City:CHESNEE
Mailing Address - State:SC
Mailing Address - Zip Code:29323-1226
Mailing Address - Country:US
Mailing Address - Phone:864-461-3113
Mailing Address - Fax:864-461-9689
Practice Address - Street 1:128 W CHEROKEE ST
Practice Address - Street 2:
Practice Address - City:CHESNEE
Practice Address - State:SC
Practice Address - Zip Code:29323-1226
Practice Address - Country:US
Practice Address - Phone:864-461-3113
Practice Address - Fax:864-461-9689
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-07
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice