Provider Demographics
NPI:1366642092
Name:DENNIS L WACK PH.D LLC
Entity Type:Organization
Organization Name:DENNIS L WACK PH.D LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:L
Authorized Official - Last Name:WACK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:303-421-1896
Mailing Address - Street 1:4045 WADSWORTH BLVD
Mailing Address - Street 2:SUITE 308
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-4642
Mailing Address - Country:US
Mailing Address - Phone:303-421-1896
Mailing Address - Fax:303-237-3589
Practice Address - Street 1:4045 WADSWORTH BLVD
Practice Address - Street 2:SUITE 308
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-4642
Practice Address - Country:US
Practice Address - Phone:303-421-1896
Practice Address - Fax:303-237-3589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-20
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1083261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO537078Medicare PIN