Provider Demographics
NPI:1750446407
Name:WAZAC, DENNIS M (DC)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:M
Last Name:WAZAC
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 BLUE RAVINE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-3893
Mailing Address - Country:US
Mailing Address - Phone:916-985-7575
Mailing Address - Fax:
Practice Address - Street 1:231 BLUE RAVINE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-3893
Practice Address - Country:US
Practice Address - Phone:916-985-7575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-23
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC26511111NR0400X, 111NX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
No111NX0100XChiropractic ProvidersChiropractorOccupational Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ62244ZOtherBLUE SHIELD
CAZZZ62244ZOtherBLUE SHIELD