Provider Demographics
NPI:1295914042
Name:HENDERSON, KENNETH MANGO (DDS)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:MANGO
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 1:8608 PRESTON RD
Mailing Address - Street 2:SUITE 112
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-3316
Mailing Address - Country:US
Mailing Address - Phone:888-749-3297
Mailing Address - Fax:
Practice Address - Street 1:8608 PRESTON RD
Practice Address - Street 2:SUITE 112
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-3316
Practice Address - Country:US
Practice Address - Phone:888-749-3297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-29
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX236171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice