Provider Demographics
NPI:1689727554
Name:HENRY, GOLY RICE JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:GOLY
Middle Name:RICE
Last Name:HENRY
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 CHERRY STREET
Mailing Address - Street 2:
Mailing Address - City:MARKS
Mailing Address - State:MS
Mailing Address - Zip Code:38646-1209
Mailing Address - Country:US
Mailing Address - Phone:662-326-8818
Mailing Address - Fax:662-326-2576
Practice Address - Street 1:304 CHERRY STREET
Practice Address - Street 2:
Practice Address - City:MARKS
Practice Address - State:MS
Practice Address - Zip Code:38646-1209
Practice Address - Country:US
Practice Address - Phone:662-326-8818
Practice Address - Fax:662-326-2576
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS155973122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00063195Medicaid