Provider Demographics
NPI:1770799074
Name:HENRY, SARITA M (DDS)
Entity type:Individual
Prefix:
First Name:SARITA
Middle Name:M
Last Name:HENRY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1217 ROYAL DR
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094
Mailing Address - Country:US
Mailing Address - Phone:770-922-6655
Mailing Address - Fax:770-388-0521
Practice Address - Street 1:1217 ROYAL DR
Practice Address - Street 2:STE 262
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094
Practice Address - Country:US
Practice Address - Phone:770-922-6655
Practice Address - Fax:770-388-0521
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0122411223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000900974AMedicaid