Provider Demographics
NPI:1295799963
Name:HENDERSON, JAMES MARTIN (MD/DDS)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:MARTIN
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:MD/DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 MORRIS ST
Mailing Address - Street 2:SUITE 304
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1842
Mailing Address - Country:US
Mailing Address - Phone:304-388-7782
Mailing Address - Fax:304-388-7788
Practice Address - Street 1:415 MORRIS ST
Practice Address - Street 2:SUITE 309
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1842
Practice Address - Country:US
Practice Address - Phone:304-388-3290
Practice Address - Fax:304-388-3186
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20470204E00000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV4002055001Medicaid
850000287OtherRAILROAD MEDICARE
WV4002055-000Medicaid
HE4054512Medicare PIN
WV4002055001Medicaid
H41479Medicare UPIN
HE4054511Medicare PIN