MEDICARE: DR. EDMOND HERBERT HENKEN DDS, MS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	32465	CA

General Provider Information

NPI Number	:	1528183316
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EDMOND HERBERT HENKEN DDS, MS

Provider Business Mailing Address
First Line	:	1171 PUERTA DEL SOL
Second Line	:	SUITE B
City	:	SAN CLEMENTE
State	:	CA
Zip	:	92673-6343
Country	:	US
Telephone Number	:	949-661-3336
Fax Number	:	949-366-0094

Provider Business Practice Location Address
First Line	:	1171 PUERTA DEL SOL
Second Line	:	SUITE B
City	:	SAN CLEMENTE
State	:	CA
Zip	:	92673-6343
Country	:	US
Telephone Number	:	949-661-3336
Fax Number	:	949-366-0094

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/20/2007
Last Update Date	:	04/17/2008

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