Provider Demographics
NPI:1689783334
Name:HENDRICKSEN, ROBERT PAUL (DDS MS)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:PAUL
Last Name:HENDRICKSEN
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7265 FAR HILLS AVE
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4206
Mailing Address - Country:US
Mailing Address - Phone:937-435-4924
Mailing Address - Fax:937-435-6447
Practice Address - Street 1:7265 FAR HILLS AVE
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4206
Practice Address - Country:US
Practice Address - Phone:937-435-4924
Practice Address - Fax:937-435-6447
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300156801223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
0457472Medicare ID - Type Unspecified