Provider Demographics
NPI:1992866875
Name:HENDERSON, CAROL
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 MAIN ST # A
Mailing Address - Street 2:
Mailing Address - City:MARBLE FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:78654-5715
Mailing Address - Country:US
Mailing Address - Phone:830-798-0844
Mailing Address - Fax:830-798-0744
Practice Address - Street 1:308 MAIN ST # A
Practice Address - Street 2:
Practice Address - City:MARBLE FALLS
Practice Address - State:TX
Practice Address - Zip Code:78654-5715
Practice Address - Country:US
Practice Address - Phone:830-798-0844
Practice Address - Fax:830-798-0744
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20242122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist