1184714404 NPI number — DR. TODD MATTHEW HENDRICKSON D.M.D

Table of content: DR. TODD MATTHEW HENDRICKSON D.M.D (NPI 1184714404)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184714404 NPI number — DR. TODD MATTHEW HENDRICKSON D.M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDRICKSON
Provider First Name:
TODD
Provider Middle Name:
MATTHEW
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.M.D
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184714404
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/26/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4949 PROFESSIONAL PARK DR
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
KANNAPOLIS
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28081-8637
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-938-0559
Provider Business Mailing Address Fax Number:
888-651-3483

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4949 PROFESSIONAL PARK DR
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
KANNAPOLIS
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28081-8637
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-938-0559
Provider Business Practice Location Address Fax Number:
888-651-3483
Provider Enumeration Date:
10/15/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  8280 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)