Healthcare Provider Details

I. General information

NPI: 1295799963
Provider Name (Legal Business Name): JAMES MARTIN HENDERSON M.D./DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 06/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 MORRIS ST SUITE 309
CHARLESTON WV
25301-1842
US

IV. Provider business mailing address

415 MORRIS ST SUITE 304
CHARLESTON WV
25301-1842
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-3290
  • Fax: 304-388-3186
Mailing address:
  • Phone: 304-388-7782
  • Fax: 304-388-7788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number20470
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number20470
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: