Provider Demographics
NPI:1801170931
Name:HENDERSONVILLE PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:HENDERSONVILLE PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER, DENTAL ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:ROBINSON
Authorized Official - Last Name:ROWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-659-7323
Mailing Address - Street 1:689 BLYTHE STREET CT
Mailing Address - Street 2:SUITE B
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28739-4098
Mailing Address - Country:US
Mailing Address - Phone:828-696-2227
Mailing Address - Fax:
Practice Address - Street 1:689 BLYTHE STREET CT
Practice Address - Street 2:SUITE B
Practice Address - City:HENDERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28739-4098
Practice Address - Country:US
Practice Address - Phone:828-696-2227
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-07
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC74601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5900625Medicaid