Provider Demographics
NPI:1659540557
Name:HENDERSON, JASON DEAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:DEAN
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 1:10868 SYCAMORE CT
Mailing Address - Street 2:
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95014-6558
Mailing Address - Country:US
Mailing Address - Phone:650-967-4811
Mailing Address - Fax:650-967-4811
Practice Address - Street 1:10868 SYCAMORE CT
Practice Address - Street 2:
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-6558
Practice Address - Country:US
Practice Address - Phone:650-967-4811
Practice Address - Fax:650-967-4811
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-25
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA502671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice