Provider Demographics
NPI:1184889644
Name:HENRY, MARK ALAN (DDS MS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALAN
Last Name:HENRY
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:A
Other - Last Name:HENRY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS MS PC
Mailing Address - Street 1:2050 MARQUETTE RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PERU
Mailing Address - State:IL
Mailing Address - Zip Code:61354
Mailing Address - Country:US
Mailing Address - Phone:815-223-9931
Mailing Address - Fax:815-223-9689
Practice Address - Street 1:2050 MARQUETTE RD
Practice Address - Street 2:SUITE 300
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354
Practice Address - Country:US
Practice Address - Phone:815-223-9931
Practice Address - Fax:815-223-9689
Is Sole Proprietor?:No
Enumeration Date:2008-07-24
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210017431223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics