=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053422758
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIONNE NICOLE HENDERSON DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 10/08/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 605 E 170TH ST
-----------------------------------------------------
City | SOUTH HOLLAND
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60473-3408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-893-0368
-----------------------------------------------------
Fax | 708-893-0456
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1959 E 166TH PL
-----------------------------------------------------
City | SOUTH HOLLAND
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60473-2666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-760-1856
-----------------------------------------------------
Fax | 708-895-2161
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2901017114
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 019023986
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------