Provider Demographics
NPI:1811915622
Name:HENDERSON, ROBERT W (DMD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:972 FIDDLER CREEK WAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515-6460
Mailing Address - Country:US
Mailing Address - Phone:859-971-9722
Mailing Address - Fax:859-971-9722
Practice Address - Street 1:101 DARBY DR
Practice Address - Street 2:SUITE 101
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-8715
Practice Address - Country:US
Practice Address - Phone:502-863-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7379122300000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1609000272OtherGROUP NPI