Provider Demographics
NPI:1396183935
Name:DENISON, JUSTIN JAY (OD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:JAY
Last Name:DENISON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3293 N MILWAUKEE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-4446
Mailing Address - Country:US
Mailing Address - Phone:208-322-2020
Mailing Address - Fax:
Practice Address - Street 1:3293 N MILWAUKEE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-4446
Practice Address - Country:US
Practice Address - Phone:208-322-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-05
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP - 100280152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist