Provider Demographics
NPI:1528092913
Name:IVAN K. HENDRICKSOND.D.S.,INC
Entity type:Organization
Organization Name:IVAN K. HENDRICKSOND.D.S.,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:HENDRICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:435-656-0507
Mailing Address - Street 1:720 S RIVER RD STE B210
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-5584
Mailing Address - Country:US
Mailing Address - Phone:435-656-0507
Mailing Address - Fax:
Practice Address - Street 1:720 S RIVER RD STE B210
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-5584
Practice Address - Country:US
Practice Address - Phone:435-656-0507
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT30431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty