Provider Demographics
NPI:1124175211
Name:HENDERSON, ROBERT LARRY (DMD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LARRY
Last Name:HENDERSON
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 1:903 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST LIBERTY
Mailing Address - State:KY
Mailing Address - Zip Code:41472-1023
Mailing Address - Country:US
Mailing Address - Phone:606-743-7711
Mailing Address - Fax:
Practice Address - Street 1:903 MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST LIBERTY
Practice Address - State:KY
Practice Address - Zip Code:41472-1023
Practice Address - Country:US
Practice Address - Phone:606-743-7711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4449122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60044492Medicaid