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General NPI Number Information
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NPI Number | 1992200364
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Entity Type | Individual
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Provider Name | LAUREN ALYSSIA HENDERSON
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Gender | Female
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Dates
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Enumeration Date | 03/28/2018
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Last Update Date | 07/15/2019
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Provider Practice Location Address
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Address Line | 5180 PARK AVE STE 210
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City | MEMPHIS
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State | TN
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Zip | 38119-3530
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Country | US
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Telephone | 901-763-0850
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Fax |
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Provider Business Mailing Address
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Address Line | 212 WALTER PAYTON LN
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City | RIDGELAND
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State | MS
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Zip | 39157-5011
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Country | US
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Telephone | 601-331-4467
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 10849
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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