Provider Demographics
NPI:1194806729
Name:PAUL E HENDRICKS JR DDS
Entity type:Organization
Organization Name:PAUL E HENDRICKS JR DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:HENDRICKS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:704-739-7588
Mailing Address - Street 1:203 JUNIPER STREET
Mailing Address - Street 2:
Mailing Address - City:KINGS MOUNTAIN
Mailing Address - State:NC
Mailing Address - Zip Code:28086-3220
Mailing Address - Country:US
Mailing Address - Phone:704-739-7588
Mailing Address - Fax:704-739-4352
Practice Address - Street 1:203 JUNIPER STREET
Practice Address - Street 2:
Practice Address - City:KINGS MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28086-3220
Practice Address - Country:US
Practice Address - Phone:704-739-7588
Practice Address - Fax:704-739-4352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3359122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8993746Medicaid
42253Medicare UPIN