1932116589 NPI number — RAYMOND HEATH HENDRICKSON DDS

Table of content: RAYMOND HEATH HENDRICKSON DDS (NPI 1932116589)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932116589 NPI number — RAYMOND HEATH HENDRICKSON DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDRICKSON
Provider First Name:
RAYMOND
Provider Middle Name:
HEATH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HENDRICKSON
Provider Other First Name:
R.
Provider Other Middle Name:
HEATH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DDS.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1932116589
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2230 N UNIVERSITY PARKWAY
Provider Second Line Business Mailing Address:
SUITE 8A
Provider Business Mailing Address City Name:
PROVO
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84604
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-370-0050
Provider Business Mailing Address Fax Number:
801-370-9635

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2230 N. UNIVERSITY PARKWAY
Provider Second Line Business Practice Location Address:
SUITE 8A
Provider Business Practice Location Address City Name:
PROVO
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-370-0050
Provider Business Practice Location Address Fax Number:
801-370-9635
Provider Enumeration Date:
08/02/2006

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:  51365979922 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 122300000X , with the licence number: 5136597-9922 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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