Basic Information
| Provider Information | |||||||||
| NPI: | 1992026546 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDERSON | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TUCKER | ||||||||
| OtherFirstName: | ANDREA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DMD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1010 MAIN ST S | ||||||||
| Address2: | |||||||||
| City: | MC KEE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404477089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6062877104 | ||||||||
| FaxNumber: | 6062874409 | ||||||||
| Practice Location | |||||||||
| Address1: | 1010 MAIN ST S | ||||||||
| Address2: | |||||||||
| City: | MC KEE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404477089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6062877104 | ||||||||
| FaxNumber: | 6062874409 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2010 | ||||||||
| LastUpdateDate: | 10/12/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 8909 | KY | Y | Dental Providers | Dentist | General Practice |
No ID Information.