Provider Demographics
NPI:1366938789
Name:HENDERSON, LUKE ANTHONY (DDS)
Entity type:Individual
Prefix:DR
First Name:LUKE
Middle Name:ANTHONY
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:LUKE
Other - Middle Name:ANTHONY
Other - Last Name:HENDERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:245 E CYNTHIA LN
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:TX
Mailing Address - Zip Code:78945-3418
Mailing Address - Country:US
Mailing Address - Phone:979-250-1077
Mailing Address - Fax:
Practice Address - Street 1:259 E COLORADO ST
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:TX
Practice Address - Zip Code:78945-2243
Practice Address - Country:US
Practice Address - Phone:979-968-9451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX343191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice