Healthcare Provider Details

I. General information

NPI: 1508062498
Provider Name (Legal Business Name): MICHAEL T HENRY DDS, MS, PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10564 HIGHWAY 15-501 SUITE E
SOUTHERN PINES NC
28387
US

IV. Provider business mailing address

10564 HIGHWAY 15-501 SUITE E
SOUTHERN PINES NC
28387
US

V. Phone/Fax

Practice location:
  • Phone: 910-692-7965
  • Fax: 910-692-7977
Mailing address:
  • Phone: 910-692-7965
  • Fax: 910-692-7977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number6540
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: