Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | SC2533 | SC |
NPI | 1003941204 |
---|---|
Provider Name | Dr. Carl Lenear Henderson |
First Address | Greenwood, SC 29648 |
Second Address | Greenwood, SC 29646 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/02/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
992533 | (05) | SC |