Provider Demographics
NPI:1548737208
Name:BRADLEY J HENKENIUS, DDS, PC
Entity Type:Organization
Organization Name:BRADLEY J HENKENIUS, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:HENKENIUS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:928-774-0181
Mailing Address - Street 1:710 N BEAVER ST BLDG 1
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3100
Mailing Address - Country:US
Mailing Address - Phone:928-774-0181
Mailing Address - Fax:928-774-7510
Practice Address - Street 1:710 N BEAVER ST BLDG 1
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3100
Practice Address - Country:US
Practice Address - Phone:928-774-0181
Practice Address - Fax:928-774-7510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental