Provider Demographics
NPI:1952493942
Name:HENRY, KIM (DMD)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:
Last Name:HENRY
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 1:3211 HOPE STREET
Mailing Address - Street 2:
Mailing Address - City:HAPEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30260
Mailing Address - Country:US
Mailing Address - Phone:770-961-6460
Mailing Address - Fax:770-960-6017
Practice Address - Street 1:1515 MORROW ROAD
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260
Practice Address - Country:US
Practice Address - Phone:770-961-6460
Practice Address - Fax:770-960-6017
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA91661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice