Provider Demographics
NPI:1821118480
Name:HENRIKSEN, BRENT JASON (MD, DDS)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:JASON
Last Name:HENRIKSEN
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 S. SOUTHEASTERN AVE.
Mailing Address - Street 2:RIVER RIDGE ORAL AND MAXILLOFACIAL SURGICAL CENTER
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57103
Mailing Address - Country:US
Mailing Address - Phone:605-331-5059
Mailing Address - Fax:605-275-6725
Practice Address - Street 1:1700 S. SOUTHEASTERN AVE.
Practice Address - Street 2:RIVER RIDGE ORAL AND MAXILLOFACIAL SURGICAL CENTER
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57103
Practice Address - Country:US
Practice Address - Phone:605-331-5059
Practice Address - Fax:605-275-6725
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE64281223S0112X
SDD08141223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery