Provider Demographics
NPI:1659485183
Name:HENDRICKSON, CHARLES VANCE (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:VANCE
Last Name:HENDRICKSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 232
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:TN
Mailing Address - Zip Code:38474
Mailing Address - Country:US
Mailing Address - Phone:931-379-7711
Mailing Address - Fax:931-379-7729
Practice Address - Street 1:703 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:TN
Practice Address - Zip Code:38474
Practice Address - Country:US
Practice Address - Phone:931-379-7711
Practice Address - Fax:931-379-7729
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS3102122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0015890OtherBLUE CROSS BLUE SHIELD