Healthcare Provider Details

I. General information

NPI: 1679682520
Provider Name (Legal Business Name): LANCE B. HENRY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 09/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1444 E STEARNS ST SUITE 11
FAYETTEVILLE AR
72703-6243
US

IV. Provider business mailing address

1444 E STEARNS ST SUITE 11
FAYETTEVILLE AR
72703-6243
US

V. Phone/Fax

Practice location:
  • Phone: 479-718-7546
  • Fax: 479-966-4979
Mailing address:
  • Phone: 479-718-7546
  • Fax: 479-966-4979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberE-5162
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number244446
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberE-5162
License Number StateAR
# 4
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number244446
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberE-5162
License Number StateAR
# 6
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License NumberE-5162
License Number StateAR
# 7
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number244446
License Number StateNY
# 8
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberE-5162
License Number StateAR
# 9
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number244446
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: