Provider Demographics
NPI:1013568229
Name:ANCO, DENNIS LEO (CPO, LPO)
Entity Type:Individual
Prefix:MR
First Name:DENNIS
Middle Name:LEO
Last Name:ANCO
Suffix:
Gender:M
Credentials:CPO, LPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1854 EVERGREEN DRAW
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-2306
Mailing Address - Country:US
Mailing Address - Phone:763-228-5697
Mailing Address - Fax:
Practice Address - Street 1:1854 EVERGREEN DRAW
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2306
Practice Address - Country:US
Practice Address - Phone:763-228-5697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-28
Last Update Date:2019-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1089222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CPO04135OtherAMERICAN BOARD FOR CERTIFICATION IN ORTHOTICS, PROSTHETICS, AND PEDORTHICS
MN1089OtherBOARD OF PODIATRIC MEDICINE