Healthcare Provider Details

I. General information

NPI: 1568757359
Provider Name (Legal Business Name): HENDRICKS DENTAL OFFICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2011
Last Update Date: 06/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 N MAIN ST
HENDRICKS MN
56136-9519
US

IV. Provider business mailing address

115 N MAIN ST
HENDRICKS MN
56136-9519
US

V. Phone/Fax

Practice location:
  • Phone: 507-275-3152
  • Fax: 507-275-3153
Mailing address:
  • Phone: 507-275-3152
  • Fax: 507-275-3153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8432
License Number StateMN

VIII. Authorized Official

Name: DR. ROLLAND CLIFFORD DIGRE
Title or Position: DENTIST
Credential: DDS
Phone: 507-275-3152