Provider Demographics
NPI:1073616850
Name:HENRY, WALTER ANDREW (DMD)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:ANDREW
Last Name:HENRY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4431 68TH STREET
Mailing Address - Street 2:USA DENTAC
Mailing Address - City:FT HOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76544
Mailing Address - Country:US
Mailing Address - Phone:254-287-2705
Mailing Address - Fax:254-287-1786
Practice Address - Street 1:4431 68TH STREET
Practice Address - Street 2:USA DENTAC
Practice Address - City:FT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544
Practice Address - Country:US
Practice Address - Phone:254-287-2705
Practice Address - Fax:254-287-1786
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY61721223G0001X, 1223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
No1223G0001XDental ProvidersDentistGeneral Practice