Provider Demographics
NPI:1225162480
Name:DENNIS, JOHN MATTHEW (CAS REG)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MATTHEW
Last Name:DENNIS
Suffix:
Gender:M
Credentials:CAS REG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 221
Mailing Address - Street 2:
Mailing Address - City:SHINGLE SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:95682-0221
Mailing Address - Country:US
Mailing Address - Phone:530-677-8029
Mailing Address - Fax:
Practice Address - Street 1:2914A COLD SPRINGS RD
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-4220
Practice Address - Country:US
Practice Address - Phone:530-642-1715
Practice Address - Fax:530-642-2064
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1838 REG.174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1838 REG.OtherCAS REG.