Provider Demographics
NPI:1083982672
Name:HENDRICKSON, TARA LYNN (RDH, EPDH)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LYNN
Last Name:HENDRICKSON
Suffix:
Gender:F
Credentials:RDH, EPDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12830 MAXFIELD CREEK RD
Mailing Address - Street 2:
Mailing Address - City:MONMOUTH
Mailing Address - State:OR
Mailing Address - Zip Code:97361-9424
Mailing Address - Country:US
Mailing Address - Phone:971-218-2987
Mailing Address - Fax:
Practice Address - Street 1:3000 MARKET ST NE
Practice Address - Street 2:SUITE 228
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-1882
Practice Address - Country:US
Practice Address - Phone:503-585-5205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-09
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH6116124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist