| NPI | 1891862850 |
|---|---|
| Former Name | STACY ANN HENDERSON |
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CO 8624) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA 21556) |
| Enumeration Date | 2006-11-28 |
| Last Update Date | 2007-07-23 |