MEDICARE: DR. THOMAS G HENDERSON D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	4028	AL

General Provider Information

NPI Number	:	1609872779
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS G HENDERSON D.M.D.

Provider Business Mailing Address
First Line	:	1100 HILLCREST RD
Second Line	:	STE B
City	:	MOBILE
State	:	AL
Zip	:	36695-3919
Country	:	US
Telephone Number	:	251-639-0090
Fax Number	:	251-633-7033

Provider Business Practice Location Address
First Line	:	1100 HILLCREST RD
Second Line	:	STE B
City	:	MOBILE
State	:	AL
Zip	:	36695-3919
Country	:	US
Telephone Number	:	251-639-0090
Fax Number	:	251-633-7033

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2005
Last Update Date	:	08/02/2007

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