Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 016072 | MO |
NPI | 1003978412 |
---|---|
Provider Name | Dr. Nelson Henry |
First Address | Jefferson City, MO 65109-6877 |
Second Address | Jefferson City, MO 65109-6877 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/12/2006 |
Last Update Date | 08/07/2007 |