MEDICARE: DR. GARY MARSHALL HENLEY D.D.S.

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	014443	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1861481707
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY MARSHALL HENLEY D.D.S.

Provider Business Mailing Address
First Line	:	6156 EVERGREEN BLVD
Second Line	:
City	:	BERKELEY
State	:	MO
Zip	:	63134-2108
Country	:	US
Telephone Number	:	314-522-1032
Fax Number	:	314-524-1292

Provider Business Practice Location Address
First Line	:	6156 EVERGREEN BLVD
Second Line	:
City	:	BERKELEY
State	:	MO
Zip	:	63134-2108
Country	:	US
Telephone Number	:	314-522-1032
Fax Number	:	314-524-1292

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

Provider Enumeration Date	:	10/13/2005
Last Update Date	:	04/05/2010

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