MEDICARE: DR. DAVID J 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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	12007864A	IN

General Provider Information

NPI Number	:	1992820773
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID J HENDERSON DDS

Provider Business Mailing Address
First Line	:	4611 EAGLEVIEW DR
Second Line	:
City	:	BLOOMINGTON
State	:	IN
Zip	:	47403-9043
Country	:	US
Telephone Number	:	812-824-2782
Fax Number	:	812-333-8933

Provider Business Practice Location Address
First Line	:	857 S AUTO MALL RD
Second Line	:
City	:	BLOOMINGTON
State	:	IN
Zip	:	47401-5447
Country	:	US
Telephone Number	:	812-333-1051
Fax Number	:	812-333-8933

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

Provider Enumeration Date	:	03/20/2007
Last Update Date	:	07/08/2007

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