Provider Demographics
NPI:1306097555
Name:HENKEN, DALE PRESTON (MD)
Entity type:Individual
Prefix:DR
First Name:DALE
Middle Name:PRESTON
Last Name:HENKEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2045
Mailing Address - Country:US
Mailing Address - Phone:541-267-5151
Mailing Address - Fax:541-266-4562
Practice Address - Street 1:1900 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2045
Practice Address - Country:US
Practice Address - Phone:541-267-5151
Practice Address - Fax:541-266-4562
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-07
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG41486208000000X
ORMD150386208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR93-0635514OtherNBMC MAIN GROUP TAX ID FOR BILLING
OR161133OtherNBMC MAIN GROUP DMAP
OR500630202Medicaid
ORMD150386OtherOREON MEDICAL LICENSE
OR1407812365OtherNBMC MAIN GROUP NPI
ORR0000WFBTVOtherNBMC MAIN GROUP MEDICARE
OR1407812365OtherNBMC MAIN GROUP NPI