Provider Demographics
NPI:1609872779
Name:HENDERSON, THOMAS G (DMD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:G
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 1:1100 HILLCREST RD
Mailing Address - Street 2:STE B
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36695-3919
Mailing Address - Country:US
Mailing Address - Phone:251-639-0090
Mailing Address - Fax:251-633-7033
Practice Address - Street 1:1100 HILLCREST RD
Practice Address - Street 2:STE B
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36695-3919
Practice Address - Country:US
Practice Address - Phone:251-639-0090
Practice Address - Fax:251-633-7033
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2007-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL40281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALU58145Medicare UPIN