Provider Demographics
NPI:1184714404
Name:HENDRICKSON, TODD MATTHEW (DMD)
Entity type:Individual
Prefix:DR
First Name:TODD
Middle Name:MATTHEW
Last Name:HENDRICKSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4949 PROFESSIONAL PARK DR
Mailing Address - Street 2:SUITE 203
Mailing Address - City:KANNAPOLIS
Mailing Address - State:NC
Mailing Address - Zip Code:28081-8637
Mailing Address - Country:US
Mailing Address - Phone:704-938-0559
Mailing Address - Fax:888-651-3483
Practice Address - Street 1:4949 PROFESSIONAL PARK DR
Practice Address - Street 2:SUITE 203
Practice Address - City:KANNAPOLIS
Practice Address - State:NC
Practice Address - Zip Code:28081-8637
Practice Address - Country:US
Practice Address - Phone:704-938-0559
Practice Address - Fax:888-651-3483
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-15
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC82801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice