Provider Demographics
NPI:1235213893
Name:HENRICKSEN, JOHN MAACK (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MAACK
Last Name:HENRICKSEN
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 1:1292 S MARKET BLVD
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-3645
Mailing Address - Country:US
Mailing Address - Phone:360-748-4481
Mailing Address - Fax:360-740-7542
Practice Address - Street 1:1292 S MARKET BLVD
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-3645
Practice Address - Country:US
Practice Address - Phone:360-748-4481
Practice Address - Fax:360-740-7542
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000039481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5334800Medicare ID - Type UnspecifiedDSHS