Provider Demographics
NPI:1932116589
Name:HENDRICKSON, RAYMOND HEATH (DDS)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:HEATH
Last Name:HENDRICKSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:R.
Other - Middle Name:HEATH
Other - Last Name:HENDRICKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:2230 N UNIVERSITY PARKWAY
Mailing Address - Street 2:SUITE 8A
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604
Mailing Address - Country:US
Mailing Address - Phone:801-370-0050
Mailing Address - Fax:801-370-9635
Practice Address - Street 1:2230 N. UNIVERSITY PARKWAY
Practice Address - Street 2:SUITE 8A
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604
Practice Address - Country:US
Practice Address - Phone:801-370-0050
Practice Address - Fax:801-370-9635
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT513659799221223G0001X
UT5136597-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice