Provider Demographics
NPI:1821296484
Name:HENDERSON, BRANDON DAVID (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:DAVID
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 1:425 E. TABERNACLE
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770
Mailing Address - Country:US
Mailing Address - Phone:435-688-1400
Mailing Address - Fax:435-688-1408
Practice Address - Street 1:425 E. TABERNACLE
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770
Practice Address - Country:US
Practice Address - Phone:435-688-1400
Practice Address - Fax:435-688-1408
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6649422-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice