Provider Demographics
NPI:1235256124
Name:BRAD HENDRICKSON D.D.S., INC.
Entity Type:Organization
Organization Name:BRAD HENDRICKSON D.D.S., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:R
Authorized Official - Last Name:HENDRICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:419-289-3325
Mailing Address - Street 1:910 KATHERINE AVE
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44805-0386
Mailing Address - Country:US
Mailing Address - Phone:419-289-3325
Mailing Address - Fax:419-289-3546
Practice Address - Street 1:910 KATHERINE AVE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OH
Practice Address - Zip Code:44805-0386
Practice Address - Country:US
Practice Address - Phone:419-289-3325
Practice Address - Fax:419-289-3546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-01-61771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty