Basic Information
Provider Information | |||||||||
NPI: | 1851455117 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HENRY | ||||||||
FirstName: | STEPHEN | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DMD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4440 FRUITVILLE RD | ||||||||
Address2: |   | ||||||||
City: | SARASOTA | ||||||||
State: | FL | ||||||||
PostalCode: | 342321926 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9413660134 | ||||||||
FaxNumber: | 9414041760 | ||||||||
Practice Location | |||||||||
Address1: | 4615 PHILIPS HWY STE 3 | ||||||||
Address2: |   | ||||||||
City: | JACKSONVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 322079506 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9045080710 | ||||||||
FaxNumber: | 8552997010 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/21/2006 | ||||||||
LastUpdateDate: | 10/10/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DN14864 | FL | Y |   | Dental Providers | Dentist | General Practice |
ID Information
ID | Type | State | Issuer | Description | 024032400 | 05 | FL |   | MEDICAID |