Provider Demographics
NPI:1316085459
Name:HENRY, CHARLES PATRICK (DDS)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:PATRICK
Last Name:HENRY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 299
Mailing Address - Street 2:
Mailing Address - City:OSSIAN
Mailing Address - State:IA
Mailing Address - Zip Code:52161-0299
Mailing Address - Country:US
Mailing Address - Phone:563-532-9860
Mailing Address - Fax:563-532-8930
Practice Address - Street 1:105 N. LYDIA STREET
Practice Address - Street 2:
Practice Address - City:OSSIAN
Practice Address - State:IA
Practice Address - Zip Code:52161
Practice Address - Country:US
Practice Address - Phone:563-532-9860
Practice Address - Fax:563-532-8930
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA66731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0007872Medicaid