Provider Demographics
NPI:1609877455
Name:DETTMANN, DENNIS E (OD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:E
Last Name:DETTMANN
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 1:5039 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-2246
Mailing Address - Country:US
Mailing Address - Phone:630-257-6493
Mailing Address - Fax:630-243-6293
Practice Address - Street 1:5039 MAIN ST
Practice Address - Street 2:
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-2246
Practice Address - Country:US
Practice Address - Phone:630-257-6493
Practice Address - Fax:630-243-6293
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007054152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046007054Medicaid
IL793960Medicare PIN
IL209322Medicare PIN
ILK07700Medicare PIN
ILK40338Medicare PIN
IL046007054Medicaid
ILK08127Medicare PIN
IL552940Medicare PIN
IL215388Medicare PIN
IL209240Medicare PIN
IL0531040001Medicare NSC