Provider Demographics
NPI:1821538265
Name:HENDERSON, MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:HENDERSON
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 1:3200 LEXINGTON AVE N STE B
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-8118
Mailing Address - Country:US
Mailing Address - Phone:651-255-8888
Mailing Address - Fax:
Practice Address - Street 1:3200 LEXINGTON AVE N STE B
Practice Address - Street 2:
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-8118
Practice Address - Country:US
Practice Address - Phone:651-255-8888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-05
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND139571223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice