MEDICARE: DR. CARSON HENLEY 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	4236	WV

General Provider Information

NPI Number	:	1851844096
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CARSON HENLEY DDS

Provider Business Mailing Address
First Line	:	1203 JEFFERSON RD
Second Line	:
City	:	SOUTH CHARLESTON
State	:	WV
Zip	:	25309-9732
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3814 MACCORKLE AVE SE
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25304-1528
Country	:	US
Telephone Number	:	304-925-0322
Fax Number	:

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

Provider Enumeration Date	:	07/23/2016
Last Update Date	:	09/17/2020

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