Provider Demographics
NPI:1720439169
Name:HENDERSON, NATHALIE KAY (DMD)
Entity Type:Individual
Prefix:
First Name:NATHALIE
Middle Name:KAY
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 S MAIN ST APT 207
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-5173
Mailing Address - Country:US
Mailing Address - Phone:404-510-2200
Mailing Address - Fax:
Practice Address - Street 1:3030 COVINGTON PIKE STE 150
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38128-5041
Practice Address - Country:US
Practice Address - Phone:901-231-1275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-27
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN102911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice