Provider Demographics
NPI:1316719438
Name:HENDRICKS CA DENTAL GROUP, INC
Entity type:Organization
Organization Name:HENDRICKS CA DENTAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GINNA
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDRICKS
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:505-603-6220
Mailing Address - Street 1:25 TEDDY BEAR TRL
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-8118
Mailing Address - Country:US
Mailing Address - Phone:505-603-6595
Mailing Address - Fax:
Practice Address - Street 1:3661 TORRANCE BLVD STE 105
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4881
Practice Address - Country:US
Practice Address - Phone:310-543-3292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty