Provider Demographics
NPI:1306023213
Name:HENRIQUEZ, MAURICIO JESUS (LD)
Entity Type:Individual
Prefix:MR
First Name:MAURICIO
Middle Name:JESUS
Last Name:HENRIQUEZ
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 164TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98008-4637
Mailing Address - Country:US
Mailing Address - Phone:425-417-6091
Mailing Address - Fax:
Practice Address - Street 1:163 164TH AVE SE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98008-4637
Practice Address - Country:US
Practice Address - Phone:425-417-6091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-23
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN00000313122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist