Provider Demographics
NPI:1255745378
Name:HENSEN, JERICK WILLIAM
Entity type:Individual
Prefix:DR
First Name:JERICK
Middle Name:WILLIAM
Last Name:HENSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 37TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-7240
Mailing Address - Country:US
Mailing Address - Phone:701-852-5595
Mailing Address - Fax:701-852-2669
Practice Address - Street 1:1300 37TH AVE SW
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-7240
Practice Address - Country:US
Practice Address - Phone:701-852-5595
Practice Address - Fax:701-852-2669
Is Sole Proprietor?:No
Enumeration Date:2014-06-17
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND22231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND41311Medicaid