Provider Demographics
NPI:1528228368
Name:JON A. HENDRICKSON, DDS INC.
Entity Type:Organization
Organization Name:JON A. HENDRICKSON, DDS INC.
Other - Org Name:TRAFALGAR FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:AXBERG
Authorized Official - Last Name:HENDRICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-878-4990
Mailing Address - Street 1:245 N STATE ROAD 135
Mailing Address - Street 2:
Mailing Address - City:TRAFALGAR
Mailing Address - State:IN
Mailing Address - Zip Code:46181-8663
Mailing Address - Country:US
Mailing Address - Phone:317-878-4990
Mailing Address - Fax:317-878-9030
Practice Address - Street 1:245 N STATE ROAD 135
Practice Address - Street 2:
Practice Address - City:TRAFALGAR
Practice Address - State:IN
Practice Address - Zip Code:46181-8663
Practice Address - Country:US
Practice Address - Phone:317-878-4990
Practice Address - Fax:317-878-9030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120099691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1083628481OtherNATIONAL PROVIDER IDENTIFIER
IN200183090AMedicaid