MEDICARE: DR. CHARLES VANCE HENDRICKSON DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DS3102	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0015890	OTHER	TN	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1659485183
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES VANCE HENDRICKSON DMD

Provider Business Mailing Address
First Line	:	PO BOX 232
Second Line	:
City	:	MT PLEASANT
State	:	TN
Zip	:	38474
Country	:	US
Telephone Number	:	931-379-7711
Fax Number	:	931-379-7729

Provider Business Practice Location Address
First Line	:	703 N MAIN ST
Second Line	:
City	:	MT PLEASANT
State	:	TN
Zip	:	38474
Country	:	US
Telephone Number	:	931-379-7711
Fax Number	:	931-379-7729

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2006
Last Update Date	:	07/08/2007

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