Provider Demographics
NPI:1376100321
Name:DENNIS, ROBERT JR
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:DENNIS
Suffix:JR
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 1:608 HARDEMAN AVE
Mailing Address - Street 2:
Mailing Address - City:FORT VALLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31030-3438
Mailing Address - Country:US
Mailing Address - Phone:478-957-8447
Mailing Address - Fax:
Practice Address - Street 1:608 HARDEMAN AVE
Practice Address - Street 2:
Practice Address - City:FORT VALLEY
Practice Address - State:GA
Practice Address - Zip Code:31030-3438
Practice Address - Country:US
Practice Address - Phone:478-957-8447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-24
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA222116373732Medicaid
GA84-1880551OtherIRS