Provider Demographics
NPI:1083628481
Name:HENDRICKSON, JON AXBERG (DDS)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:AXBERG
Last Name:HENDRICKSON
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 1:245 N STATE ROAD 135
Mailing Address - Street 2:
Mailing Address - City:TRAFALGAR
Mailing Address - State:IN
Mailing Address - Zip Code:46181-8663
Mailing Address - Country:US
Mailing Address - Phone:317-878-4990
Mailing Address - Fax:317-878-9030
Practice Address - Street 1:245 N STATE ROAD 135
Practice Address - Street 2:
Practice Address - City:TRAFALGAR
Practice Address - State:IN
Practice Address - Zip Code:46181-8663
Practice Address - Country:US
Practice Address - Phone:317-878-4990
Practice Address - Fax:317-878-9030
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120099691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice