Provider Demographics
NPI:1134293632
Name:HENKENIUS, BRADLEY JOSEPH (DDS)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:JOSEPH
Last Name:HENKENIUS
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 1:1005 W BOULDER LN
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-1126
Mailing Address - Country:US
Mailing Address - Phone:928-774-9660
Mailing Address - Fax:928-774-7510
Practice Address - Street 1:710 N BEAVER ST
Practice Address - Street 2:BLDG 1
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3100
Practice Address - Country:US
Practice Address - Phone:928-774-0181
Practice Address - Fax:928-774-7510
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ65141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice