Provider Demographics
NPI:1356458293
Name:HENRICKSEN, J SCOTT (DDS)
Entity Type:Individual
Prefix:DR
First Name:J
Middle Name:SCOTT
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 1:701 N 182ND ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-4402
Mailing Address - Country:US
Mailing Address - Phone:206-542-7600
Mailing Address - Fax:206-542-7727
Practice Address - Street 1:701 N 182ND ST
Practice Address - Street 2:SUITE 102
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98133-4402
Practice Address - Country:US
Practice Address - Phone:206-542-7600
Practice Address - Fax:206-542-7727
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA5431122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5007703OtherMAA