Provider Demographics
NPI:1780011213
Name:HENDERSONVILLE DENTISTRY
Entity type:Organization
Organization Name:HENDERSONVILLE DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:CLAIRE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:828-692-3933
Mailing Address - Street 1:687 BLYTHE STREET CT STE A
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28739-4054
Mailing Address - Country:US
Mailing Address - Phone:828-692-3933
Mailing Address - Fax:828-692-9946
Practice Address - Street 1:687 BLYTHE STREET CT STE A
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28739-4054
Practice Address - Country:US
Practice Address - Phone:828-692-3933
Practice Address - Fax:828-692-9946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-30
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC92851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC97556OtherBLUE CROSS BLUE SHIELD OF NC
NC7997556Medicaid
000755006OtherUNITED CONCORDIA