Healthcare Provider Details

I. General information

NPI: 1043664188
Provider Name (Legal Business Name): BRAXTON HENDERSON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2016
Last Update Date: 02/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 NICHOLAS RD STE F
GREENSBORO NC
27409-3404
US

IV. Provider business mailing address

316 MAIN ST
OXFORD NC
27565-3323
US

V. Phone/Fax

Practice location:
  • Phone: 252-213-8484
  • Fax:
Mailing address:
  • Phone: 252-213-8484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS040743
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number10942
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number0401416381
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: