Provider Demographics
NPI:1932284999
Name:HENRY, ANDREA (DDS)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:HENRY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8110 CORDOVA RD
Mailing Address - Street 2:SUITE 125
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-0520
Mailing Address - Country:US
Mailing Address - Phone:901-755-0001
Mailing Address - Fax:901-755-9679
Practice Address - Street 1:8110 CORDOVA RD
Practice Address - Street 2:SUITE 125
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016-0520
Practice Address - Country:US
Practice Address - Phone:901-755-0001
Practice Address - Fax:901-755-9679
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN074811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1520260Medicaid