Provider Demographics
NPI:1720431406
Name:HENDERSON, KATELYN MARIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:KATELYN
Middle Name:MARIE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:KATELYN
Other - Middle Name:
Other - Last Name:TOBALSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:6820 MATTHEWS MINT HILL RD STE 204
Mailing Address - Street 2:
Mailing Address - City:MINT HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28227-9492
Mailing Address - Country:US
Mailing Address - Phone:704-732-2629
Mailing Address - Fax:
Practice Address - Street 1:6820 MATTHEWS MINT HILL RD STE 204
Practice Address - Street 2:
Practice Address - City:MINT HILL
Practice Address - State:NC
Practice Address - Zip Code:28227-9492
Practice Address - Country:US
Practice Address - Phone:704-800-0255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-19
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC151094122300000X
NC105901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist