=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962407866
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBIN J HENDERSON DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 625 6TH STREET
-----------------------------------------------------
City | CLARKSTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99403-2010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-758-6071
-----------------------------------------------------
Fax | 509-758-6146
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 625 6TH ST
-----------------------------------------------------
City | CLARKSTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99403-2010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-758-6071
-----------------------------------------------------
Fax | 509-758-6146
-----------------------------------------------------
=====================================================
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 | DE00008250
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------