Provider Demographics
NPI:1720146418
Name:HENRIE, DERREK (DDS)
Entity type:Individual
Prefix:
First Name:DERREK
Middle Name:
Last Name:HENRIE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 E BROOMFIELD ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-4437
Mailing Address - Country:US
Mailing Address - Phone:989-772-4581
Mailing Address - Fax:989-773-6285
Practice Address - Street 1:1110 E BROOMFIELD ST
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-4437
Practice Address - Country:US
Practice Address - Phone:989-772-4581
Practice Address - Fax:989-773-6285
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010175401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice