Provider Demographics
NPI:1740215144
Name:DENNISTON, ROBERT BRUCE (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:BRUCE
Last Name:DENNISTON
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 1:120 MADISON AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:MOUNT HOLLY
Mailing Address - State:NJ
Mailing Address - Zip Code:08060-2055
Mailing Address - Country:US
Mailing Address - Phone:609-261-1144
Mailing Address - Fax:609-267-4399
Practice Address - Street 1:120 MADISON AVE
Practice Address - Street 2:SUITE C
Practice Address - City:MOUNT HOLLY
Practice Address - State:NJ
Practice Address - Zip Code:08060-2055
Practice Address - Country:US
Practice Address - Phone:609-261-1144
Practice Address - Fax:609-267-4399
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA030469207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2409607Medicaid
111180Medicare ID - Type Unspecified
NJ2409607Medicaid