Provider Demographics
NPI:1629291380
Name:HENRICKSON, MIKE R (DDS)
Entity Type:Individual
Prefix:DR
First Name:MIKE
Middle Name:R
Last Name:HENRICKSON
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 1:1560 BEAM AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-1191
Mailing Address - Country:US
Mailing Address - Phone:651-777-8900
Mailing Address - Fax:651-777-8908
Practice Address - Street 1:1560 BEAM AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1191
Practice Address - Country:US
Practice Address - Phone:651-777-8900
Practice Address - Fax:651-777-8908
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND119201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice