Healthcare Provider Details

I. General information

NPI: 1306097555
Provider Name (Legal Business Name): DALE PRESTON HENKEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2008
Last Update Date: 09/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 WOODLAND DR
COOS BAY OR
97420-2045
US

IV. Provider business mailing address

1900 WOODLAND DR
COOS BAY OR
97420-2045
US

V. Phone/Fax

Practice location:
  • Phone: 541-267-5151
  • Fax: 541-266-4562
Mailing address:
  • Phone: 541-267-5151
  • Fax: 541-266-4562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG41486
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD150386
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier93-0635514
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerNBMC MAIN GROUP TAX ID FOR BILLING
# 2
Identifier161133
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerNBMC MAIN GROUP DMAP
# 3
Identifier500630202
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 4
IdentifierMD150386
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerOREON MEDICAL LICENSE
# 5
Identifier1407812365
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerNBMC MAIN GROUP NPI
# 6
IdentifierR0000WFBTV
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerNBMC MAIN GROUP MEDICARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: