Provider Demographics
NPI:1740444827
Name:MYRON HENRICKSON, DDS PA
Entity type:Organization
Organization Name:MYRON HENRICKSON, DDS PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MYRON
Authorized Official - Middle Name:A
Authorized Official - Last Name:HENRICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-777-8900
Mailing Address - Street 1:1560 BEAM AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-1191
Mailing Address - Country:US
Mailing Address - Phone:651-777-8900
Mailing Address - Fax:
Practice Address - Street 1:1560 BEAM AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1191
Practice Address - Country:US
Practice Address - Phone:651-777-8900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-17
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND9492122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty