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General NPI Number Information
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NPI Number | 1700302742
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Entity Type | Organization
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Legal Business Name | MICHAEL R HENRICKSON DDS, PLLC
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Dates
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Enumeration Date | 08/22/2017
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Last Update Date | 08/22/2017
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Provider Practice Location Address
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Address Line | 14050 NICOLLET AVE 205
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City | BURNSVILLE
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State | MN
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Zip | 55337
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Country | US
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Telephone | 952-435-4177
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Fax |
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Provider Business Mailing Address
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Address Line | 14050 NICOLLET AVE 205
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City | BURNSVILLE
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State | MN
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Zip | 55337
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Country | US
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Telephone | 952-435-4177
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | CRYSTAL MILLER
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Credential | OM
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Telephone | 651-777-8900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State | MN
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