Provider Demographics
NPI:1205875887
Name:HENRICKSON, SUSAN ELLA (DMD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:ELLA
Last Name:HENRICKSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 N SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18940-1514
Mailing Address - Country:US
Mailing Address - Phone:215-579-9900
Mailing Address - Fax:215-579-9035
Practice Address - Street 1:219 N SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:PA
Practice Address - Zip Code:18940-1514
Practice Address - Country:US
Practice Address - Phone:215-579-9900
Practice Address - Fax:215-579-9035
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS022540L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist