Provider Demographics
NPI:1023231776
Name:HENRICKSON, MYRON A (DDS)
Entity type:Individual
Prefix:DR
First Name:MYRON
Middle Name:A
Last Name:HENRICKSON
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 1:2200 COUNTY ROAD C W STE 2210
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-2551
Mailing Address - Country:US
Mailing Address - Phone:952-241-5899
Mailing Address - Fax:
Practice Address - Street 1:17436 KENWOOD TRL
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044
Practice Address - Country:US
Practice Address - Phone:952-241-5899
Practice Address - Fax:952-241-5897
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND94921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice