Provider Demographics
NPI:1821410663
Name:DANIEL M. HENRICKSEN DDS MS PLLC
Entity Type:Organization
Organization Name:DANIEL M. HENRICKSEN DDS MS PLLC
Other - Org Name:HENRICKSEN FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:HENRICKSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:360-748-4481
Mailing Address - Street 1:1292 S MARKET BLVD
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-3645
Mailing Address - Country:US
Mailing Address - Phone:360-748-4481
Mailing Address - Fax:360-740-7542
Practice Address - Street 1:1292 S MARKET BLVD
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-3645
Practice Address - Country:US
Practice Address - Phone:360-748-4481
Practice Address - Fax:360-740-7542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-14
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA5334800261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2043379Medicaid
WA5334800Medicaid