MEDICARE: DERREK HENRIE DDS

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	1223G0001X	General Practice Dentistry	2901017540	MI

General Provider Information

NPI Number	:	1720146418
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DERREK HENRIE DDS

Provider Business Mailing Address
First Line	:	1110 E BROOMFIELD ST
Second Line	:
City	:	MOUNT PLEASANT
State	:	MI
Zip	:	48858-4437
Country	:	US
Telephone Number	:	989-772-4581
Fax Number	:	989-773-6285

Provider Business Practice Location Address
First Line	:	1110 E BROOMFIELD ST
Second Line	:
City	:	MOUNT PLEASANT
State	:	MI
Zip	:	48858-4437
Country	:	US
Telephone Number	:	989-772-4581
Fax Number	:	989-773-6285

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

Provider Enumeration Date	:	12/05/2006
Last Update Date	:	05/25/2022

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