Provider Demographics
NPI:1679627616
Name:HENSON, DOUGLAS C JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:C
Last Name:HENSON
Suffix:JR
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 1:600 OGLETHORPE AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2263
Mailing Address - Country:US
Mailing Address - Phone:706-353-2575
Mailing Address - Fax:706-353-6707
Practice Address - Street 1:600 OGLETHORPE AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2263
Practice Address - Country:US
Practice Address - Phone:706-353-2575
Practice Address - Fax:706-353-6707
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA100341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice