Provider Demographics
NPI:1689686305
Name:HENRY, HAROLD EDWIN (DDS)
Entity Type:Individual
Prefix:MR
First Name:HAROLD
Middle Name:EDWIN
Last Name:HENRY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:H
Other - Middle Name:E
Other - Last Name:HENRY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:200 SAINT THOMAS DRIVE
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062
Mailing Address - Country:US
Mailing Address - Phone:304-723-7200
Mailing Address - Fax:304-723-4460
Practice Address - Street 1:200 SAINT THOMAS DRIVE
Practice Address - Street 2:
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062
Practice Address - Country:US
Practice Address - Phone:304-723-7200
Practice Address - Fax:304-723-4460
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2603122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0136873000Medicaid