MEDICARE: DR. CARL EDWARD HENLEY D.D,S, F.A.G.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	019018806	IL

General Provider Information

NPI Number	:	1891951786
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CARL EDWARD HENLEY D.D,S, F.A.G.D

Provider Business Mailing Address
First Line	:	931 W 75TH ST
Second Line	:	STE. 107
City	:	NAPERVILLE
State	:	IL
Zip	:	60565-1294
Country	:	US
Telephone Number	:	630-357-9393
Fax Number	:	630-357-9380

Provider Business Practice Location Address
First Line	:	931 W 75TH ST
Second Line	:	STE. 107
City	:	NAPERVILLE
State	:	IL
Zip	:	60565-1294
Country	:	US
Telephone Number	:	630-357-9393
Fax Number	:	630-357-9380

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/31/2008
Last Update Date	:	07/31/2008

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