Provider Demographics
NPI:1295898310
Name:HENDRICKSON, RONALD GAIL (DDS)
Entity type:Individual
Prefix:MR
First Name:RONALD
Middle Name:GAIL
Last Name:HENDRICKSON
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 1:56 EAST 100 SOUTH
Mailing Address - Street 2:
Mailing Address - City:JEROME
Mailing Address - State:ID
Mailing Address - Zip Code:83338
Mailing Address - Country:US
Mailing Address - Phone:208-324-3596
Mailing Address - Fax:
Practice Address - Street 1:128 SOUTH ADAMS
Practice Address - Street 2:
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338
Practice Address - Country:US
Practice Address - Phone:208-324-3596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD15541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice