Provider Demographics
NPI:1699820043
Name:HENIFIN, RICHARD WAYNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:WAYNE
Last Name:HENIFIN
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 1:493 MAIN ST STE C
Mailing Address - Street 2:
Mailing Address - City:DIAMOND SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:95619-9173
Mailing Address - Country:US
Mailing Address - Phone:530-626-5810
Mailing Address - Fax:530-626-6560
Practice Address - Street 1:493 MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:DIAMOND SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:95619-9173
Practice Address - Country:US
Practice Address - Phone:530-626-5810
Practice Address - Fax:530-626-6560
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA275261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice