Provider Demographics
NPI:1861481707
Name:HENLEY, GARY MARSHALL (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:MARSHALL
Last Name:HENLEY
Suffix:
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 1:6156 EVERGREEN BLVD
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:MO
Mailing Address - Zip Code:63134-2108
Mailing Address - Country:US
Mailing Address - Phone:314-522-1032
Mailing Address - Fax:314-524-1292
Practice Address - Street 1:6156 EVERGREEN BLVD
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:MO
Practice Address - Zip Code:63134-2108
Practice Address - Country:US
Practice Address - Phone:314-522-1032
Practice Address - Fax:314-524-1292
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0144431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO402309207Medicaid