Provider Demographics
NPI:1003941204
Name:HENDERSON, CARL LENEAR (DMD)
Entity type:Individual
Prefix:DR
First Name:CARL
Middle Name:LENEAR
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:PO BOX 1193
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29648
Mailing Address - Country:US
Mailing Address - Phone:864-229-2224
Mailing Address - Fax:
Practice Address - Street 1:1217 SOUTH MAIN ST
Practice Address - Street 2:CORRESPONDENCE ONLY POB 1193
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646
Practice Address - Country:US
Practice Address - Phone:864-229-2224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC2533122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC992533Medicaid