Healthcare Provider Details

I. General information

NPI: 1952810715
Provider Name (Legal Business Name): HENDRICKS DENTAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 SAINT MICHAELS DR STE B
SANTA FE NM
87505-7674
US

IV. Provider business mailing address

444 SAINT MICHAELS DR STE B
SANTA FE NM
87505-7674
US

V. Phone/Fax

Practice location:
  • Phone: 505-989-8749
  • Fax:
Mailing address:
  • Phone: 505-989-8749
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number4731
License Number StateNM

VIII. Authorized Official

Name: VIRGINIA HENDRICKS
Title or Position: GENERAL MANAGER
Credential:
Phone: 505-603-6220