Provider Demographics
NPI:1770244972
Name:HENDERSON & ASSOCIATES DDS PC DBA JOLLY SMILES MOBILE DENTAL SERVICES
Entity Type:Organization
Organization Name:HENDERSON & ASSOCIATES DDS PC DBA JOLLY SMILES MOBILE DENTAL SERVICES
Other - Org Name:JOLLY SMILES DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELBERT
Authorized Official - Middle Name:M
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:586-873-1014
Mailing Address - Street 1:645 GRISWOLD ST STE 224
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48226-4014
Mailing Address - Country:US
Mailing Address - Phone:586-873-1014
Mailing Address - Fax:248-864-8648
Practice Address - Street 1:645 GRISWOLD ST STE 224
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48226-4014
Practice Address - Country:US
Practice Address - Phone:586-873-1014
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-10
Last Update Date:2022-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty