Provider Demographics
NPI:1568534022
Name:DENNIS, WADE MATTHEW (OD)
Entity Type:Individual
Prefix:DR
First Name:WADE
Middle Name:MATTHEW
Last Name:DENNIS
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 1:5912 GEMINI DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53718-2944
Mailing Address - Country:US
Mailing Address - Phone:608-469-2794
Mailing Address - Fax:
Practice Address - Street 1:1740 C N. SPRING ST.
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916
Practice Address - Country:US
Practice Address - Phone:920-885-3318
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2290-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U43121Medicare UPIN