Provider Demographics
NPI:1639332448
Name:HENDERSON, SHIRLEY ANN (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHIRLEY
Middle Name:ANN
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:747 BRAWLEY SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117
Mailing Address - Country:US
Mailing Address - Phone:704-663-3001
Mailing Address - Fax:704-663-6954
Practice Address - Street 1:747 BRAWLEY SCHOOL RD
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117
Practice Address - Country:US
Practice Address - Phone:704-663-3001
Practice Address - Fax:704-663-6954
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC65161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice