Provider Demographics
NPI:1851598213
Name:HENDRICKSON, AMANDA (DDS)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:HENDRICKSON
Suffix:
Gender:F
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:PO BOX 867
Mailing Address - Street 2:
Mailing Address - City:BRISTOW
Mailing Address - State:OK
Mailing Address - Zip Code:74010-0867
Mailing Address - Country:US
Mailing Address - Phone:918-367-3361
Mailing Address - Fax:918-367-7076
Practice Address - Street 1:121 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BRISTOW
Practice Address - State:OK
Practice Address - Zip Code:74010-2429
Practice Address - Country:US
Practice Address - Phone:918-367-3361
Practice Address - Fax:918-367-7076
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK59481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice