Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223X0400X | Orthodontists | 19577 | TX |
NPI | 1073672952 |
---|---|
Provider Name | Marlon Henderson |
First Address | Richardson, TX 75081-6612 |
Second Address | Dallas, TX 75237-2596 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/12/2006 |
Last Update Date | 08/07/2007 |