Provider Demographics
NPI:1467153387
Name:DENNIS, UNKNOWN (RD)
Entity Type:Individual
Prefix:
First Name:UNKNOWN
Middle Name:
Last Name:DENNIS
Suffix:
Gender:M
Credentials:RD
Other - Prefix:MR
Other - First Name:DENNIS
Other - Middle Name:
Other - Last Name:DENNIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:24 JONES ST APT 407
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07103-3843
Mailing Address - Country:US
Mailing Address - Phone:862-872-2880
Mailing Address - Fax:
Practice Address - Street 1:140 BERGEN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-2425
Practice Address - Country:US
Practice Address - Phone:862-872-2880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-16
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ86325724133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered