=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225231517
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT MICHAEL HENDERSON DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6222 W 9TH AVE AMARILLO COLLEGE DENTAL CLINIC
-----------------------------------------------------
City | AMARILLO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79106-0701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-356-3639
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6305 SUNLAKE DR
-----------------------------------------------------
City | AMARILLO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79124-1215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-670-0596
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 13753
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------