Provider Demographics
NPI:1073605911
Name:HENICK, BERTRAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:BERTRAM
Middle Name:
Last Name:HENICK
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 1:26560 AGOURA RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CALABASAS
Mailing Address - State:CA
Mailing Address - Zip Code:91302-1926
Mailing Address - Country:US
Mailing Address - Phone:818-871-9416
Mailing Address - Fax:818-865-2079
Practice Address - Street 1:26560 AGOURA RD
Practice Address - Street 2:SUITE 102
Practice Address - City:CALABASAS
Practice Address - State:CA
Practice Address - Zip Code:91302-1926
Practice Address - Country:US
Practice Address - Phone:818-871-9416
Practice Address - Fax:818-865-2079
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA161751223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics