Provider Demographics
NPI:1992026546
Name:HENDERSON, ANDREA (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:ANDREA
Other - Middle Name:
Other - Last Name:TUCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:1010 MAIN ST S
Mailing Address - Street 2:
Mailing Address - City:MC KEE
Mailing Address - State:KY
Mailing Address - Zip Code:40447-7089
Mailing Address - Country:US
Mailing Address - Phone:606-287-7104
Mailing Address - Fax:606-287-4409
Practice Address - Street 1:1010 MAIN ST S
Practice Address - Street 2:
Practice Address - City:MC KEE
Practice Address - State:KY
Practice Address - Zip Code:40447-7089
Practice Address - Country:US
Practice Address - Phone:606-287-7104
Practice Address - Fax:606-287-4409
Is Sole Proprietor?:No
Enumeration Date:2010-06-17
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY89091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice