Provider Demographics
NPI:1083978316
Name:HEATH HENDRICKSON MBR
Entity Type:Organization
Organization Name:HEATH HENDRICKSON MBR
Other - Org Name:WISDOM TEETH ONLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:HEATH
Authorized Official - Last Name:HENDRICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-370-0050
Mailing Address - Street 1:2230 N UNIVERSITY PKWY STE 8A
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-6702
Mailing Address - Country:US
Mailing Address - Phone:801-370-0050
Mailing Address - Fax:
Practice Address - Street 1:2230 N UNIVERSITY PKWY STE 8A
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-6702
Practice Address - Country:US
Practice Address - Phone:801-370-0050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-02
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT51365999221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty