MEDICARE: DR. MARK WILLIAM HENDERSON DMD

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	5078	AL

General Provider Information

NPI Number	:	1992792840
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK WILLIAM HENDERSON DMD

Provider Business Mailing Address
First Line	:	23D MEDICAL GROUP 3278 MITCHELL BLVD
Second Line	:
City	:	MOODY AFB
State	:	GA
Zip	:	31699-1500
Country	:	US
Telephone Number	:	229-257-1459
Fax Number	:

Provider Business Practice Location Address
First Line	:	23D MEDICAL GROUP 3278 MITCHELL BLVD
Second Line	:
City	:	MOODY AFB
State	:	GA
Zip	:	31699-1500
Country	:	US
Telephone Number	:	229-257-1459
Fax Number	:

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

Provider Enumeration Date	:	10/05/2005
Last Update Date	:	04/25/2018

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