Provider Demographics
NPI:1780855858
Name:HENDRICKSON, GREGG C
Entity Type:Individual
Prefix:DR
First Name:GREGG
Middle Name:C
Last Name:HENDRICKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2790 W HORIZON RIDGE PKWY
Mailing Address - Street 2:SUITE #100
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-3997
Mailing Address - Country:US
Mailing Address - Phone:702-735-3284
Mailing Address - Fax:702-733-5910
Practice Address - Street 1:2790 W HORIZON RIDGE PKWY
Practice Address - Street 2:SUITE #100
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-3997
Practice Address - Country:US
Practice Address - Phone:702-735-3284
Practice Address - Fax:702-733-5910
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-17
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV26811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice