Provider Demographics
NPI:1124293782
Name:AUBREY J HENSHAW III
Entity type:Organization
Organization Name:AUBREY J HENSHAW III
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:AUBREY
Authorized Official - Middle Name:J
Authorized Official - Last Name:HENSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:918-775-4431
Mailing Address - Street 1:PO BOX 708
Mailing Address - Street 2:
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955-0708
Mailing Address - Country:US
Mailing Address - Phone:918-775-4431
Mailing Address - Fax:918-775-4432
Practice Address - Street 1:201 S OAK ST
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-6209
Practice Address - Country:US
Practice Address - Phone:918-775-4431
Practice Address - Fax:918-775-4432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK752271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100132280BMedicaid