Provider Demographics
NPI:1548603764
Name:DENNIS, MICHAEL CONRAD (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CONRAD
Last Name:DENNIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11001 EXECUTIVE CENTER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-4393
Mailing Address - Country:US
Mailing Address - Phone:501-812-7215
Mailing Address - Fax:501-202-7006
Practice Address - Street 1:11321 INTERSTATE 30 STE 304
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72209-7067
Practice Address - Country:US
Practice Address - Phone:501-487-6010
Practice Address - Fax:501-202-7513
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-08
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-106362084P0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program