Provider Demographics
NPI:1972713972
Name:LEO S. HENRICHSEN,D.D.S., P.S
Entity type:Organization
Organization Name:LEO S. HENRICHSEN,D.D.S., P.S
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEO
Authorized Official - Middle Name:S
Authorized Official - Last Name:HENRICHSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,PS
Authorized Official - Phone:206-364-7181
Mailing Address - Street 1:5723 NE BOTHELL WAY STE D
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:WA
Mailing Address - Zip Code:98028-9404
Mailing Address - Country:US
Mailing Address - Phone:206-364-7181
Mailing Address - Fax:425-483-6056
Practice Address - Street 1:5723 NE BOTHELL WAY STE D
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:WA
Practice Address - Zip Code:98028-9404
Practice Address - Country:US
Practice Address - Phone:206-364-7181
Practice Address - Fax:425-483-6056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3280122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA01131OtherWASHINGTON DENTAL SERVICE
WA5113105Medicaid