Provider Demographics
NPI:1053422758
Name:HENDERSON, DIONNE NICOLE (DDS)
Entity type:Individual
Prefix:
First Name:DIONNE
Middle Name:NICOLE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1959 E 166TH PL
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-2666
Mailing Address - Country:US
Mailing Address - Phone:248-760-1856
Mailing Address - Fax:708-895-2161
Practice Address - Street 1:605 E 170TH ST
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-3408
Practice Address - Country:US
Practice Address - Phone:708-893-0368
Practice Address - Fax:708-893-0456
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010171141223G0001X
IL0190239861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4231409Medicaid