Provider Demographics
NPI:1851455117
Name:HENRY, STEPHEN M (DMD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:M
Last Name:HENRY
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 1:4440 FRUITVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34232-1926
Mailing Address - Country:US
Mailing Address - Phone:941-366-0134
Mailing Address - Fax:941-404-1760
Practice Address - Street 1:4615 PHILIPS HWY STE 3
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-9506
Practice Address - Country:US
Practice Address - Phone:904-508-0710
Practice Address - Fax:855-299-7010
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN148641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024032400Medicaid