Provider Demographics
NPI:1417924556
Name:POFFENROTH, DENNIS ROCKE (OD)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:ROCKE
Last Name:POFFENROTH
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:PO BOX 1138
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362
Mailing Address - Country:US
Mailing Address - Phone:505-529-2020
Mailing Address - Fax:509-529-2115
Practice Address - Street 1:22 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362
Practice Address - Country:US
Practice Address - Phone:509-529-2020
Practice Address - Fax:509-529-2115
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA980TX152W00000X
ID848152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
410016582OtherTRAVELERS MEDICARE RETIRE
910940489OtherCOMERCIAL CLAIMS
910940489OtherPREMERA BLUE CROSS
P06984OtherREGENCE WASHINGTON
0323400001OtherMC SUPPLY CIGNA DMERC REG
25764891OtherGROUP HEALTH
8886644808OtherCOMMUNITY HEALTH PLAN
T61011OtherVISION SERVICE PLAN
WA2009470Medicaid
5857519OtherAETNA
022886002OtherREGENCE OREGON
032340000OtherCIGNA
610605300OtherDEPT OF LABOR SEATTLE DFE
67003OtherDEPT OF LABOR AND INDUSTR
410016582OtherUPPR
67003OtherDEPT OF LABOR AND INDUSTR
T61011Medicare UPIN