Provider Demographics
NPI:1275699233
Name:HISE, DENNIS ALAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:ALAN
Last Name:HISE
Suffix:
Gender:M
Credentials:DMD
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 104; 1028 NORTH COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:HARRODSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40330-0104
Mailing Address - Country:US
Mailing Address - Phone:859-734-5437
Mailing Address - Fax:859-715-0818
Practice Address - Street 1:PO BOX 104; 1028 NORTH COLLEGE ST
Practice Address - Street 2:
Practice Address - City:HARRODSBURG
Practice Address - State:KY
Practice Address - Zip Code:40330-0104
Practice Address - Country:US
Practice Address - Phone:859-734-5437
Practice Address - Fax:859-715-0818
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY42641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
61-0975938OtherTAX ID #
KY60042645Medicaid
KY0972401Medicare ID - Type Unspecified