Provider Demographics
NPI:1902967177
Name:HENRY, MATTHEW JACKSON (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JACKSON
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 1:13624 MARSH HARBOR DR N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-2641
Mailing Address - Country:US
Mailing Address - Phone:305-336-0554
Mailing Address - Fax:
Practice Address - Street 1:6223 SAUTERNE DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-7728
Practice Address - Country:US
Practice Address - Phone:049-771-0568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL161751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice