Provider Demographics
NPI:1598072654
Name:HENDERSON, JEFFERY Y (DMD)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:Y
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 1:5955 ZEAMER AVENUE
Mailing Address - Street 2:673RD MDG
Mailing Address - City:JOINT BASE ELMENDORF-RICHARDSON
Mailing Address - State:AK
Mailing Address - Zip Code:99506
Mailing Address - Country:US
Mailing Address - Phone:907-580-5020
Mailing Address - Fax:
Practice Address - Street 1:5955 ZEAMER AVENUE
Practice Address - Street 2:673RD MDG
Practice Address - City:JOINT BASE ELMENDORF-RICHARDSON
Practice Address - State:AK
Practice Address - Zip Code:99506
Practice Address - Country:US
Practice Address - Phone:907-580-5020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-09
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60169130122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist