Provider Demographics
NPI:1215927181
Name:HENRY, MITCHELL JAY (MD, DDS)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:JAY
Last Name:HENRY
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 S 16TH ST
Mailing Address - Street 2:STE 300
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68502
Mailing Address - Country:US
Mailing Address - Phone:402-435-0044
Mailing Address - Fax:402-435-7010
Practice Address - Street 1:2222 S 16TH ST
Practice Address - Street 2:SUITE 300
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68502
Practice Address - Country:US
Practice Address - Phone:402-435-0044
Practice Address - Fax:402-435-7010
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-24
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE18887174400000X
NE55041223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialist
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47080208100Medicaid
NEF50473Medicare UPIN
NE268000Medicare ID - Type Unspecified