Provider Demographics
NPI:1013079656
Name:HENDERSON, WALTER E (DDS)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:E
Last Name:HENDERSON
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 1:179 N CHURCH AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-5265
Mailing Address - Country:US
Mailing Address - Phone:479-442-6512
Mailing Address - Fax:479-442-7817
Practice Address - Street 1:179 N CHURCH AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701
Practice Address - Country:US
Practice Address - Phone:479-442-6512
Practice Address - Fax:479-442-7817
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN22401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice