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General NPI Number Information
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NPI Number | 1992571293
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Entity Type | Organization
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Legal Business Name | MICHAEL HENRICKSON DDS
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Dates
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Enumeration Date | 11/28/2023
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Last Update Date | 11/28/2023
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Provider Practice Location Address
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Address Line | 14050 NICOLLET AVE STE 205
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City | BURNSVILLE
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State | MN
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Zip | 55337-5738
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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 | 1560 BEAM AVE STE A
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City | MAPLEWOOD
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State | MN
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Zip | 55109-1171
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | AUTHORIZED OFFICIAL
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Name | MIKE RYAN HENRICKSON
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Credential | DDS
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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 | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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