MEDICARE: DR. HARRY GEORGE HENDERSON DDS

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	019015128	IL

General Provider Information

NPI Number	:	1619101631
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HARRY GEORGE HENDERSON DDS

Provider Business Mailing Address
First Line	:	1835 KINGSHIGHWAY
Second Line	:
City	:	EAST SAINT LOUIS
State	:	IL
Zip	:	62204-2135
Country	:	US
Telephone Number	:	618-482-7922
Fax Number	:

Provider Business Practice Location Address
First Line	:	1835 KINGSHIGHWAY
Second Line	:
City	:	EAST SAINT LOUIS
State	:	IL
Zip	:	62204-2135
Country	:	US
Telephone Number	:	618-482-7922
Fax Number	:

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

Provider Enumeration Date	:	05/05/2009
Last Update Date	:	05/05/2009

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