Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0700X | Prosthodontist | 61553 | CA |
NPI | 1194072231 |
---|---|
Provider Name | Dr. Andrea Lynne Henderson |
First Address | Los Angeles, CA 90049-5012 |
Second Address | Los Angeles, CA 90049-5012 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/08/2012 |
Last Update Date | 08/08/2012 |