Provider Demographics
NPI:1144364217
Name:HENRY, CHARLES H (DDS PC)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:H
Last Name:HENRY
Suffix:
Gender:M
Credentials:DDS PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4343 N 21ST STREET
Mailing Address - Street 2:SUITE 208
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-0504
Mailing Address - Country:US
Mailing Address - Phone:928-284-9632
Mailing Address - Fax:928-284-6874
Practice Address - Street 1:18555 N 79TH AVE
Practice Address - Street 2:SUITE A104
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85708-8371
Practice Address - Country:US
Practice Address - Phone:928-284-9632
Practice Address - Fax:928-284-6874
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ19981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice