Provider Demographics
NPI:1760466262
Name:DENNIS, LAURENCE L (MD)
Entity Type:Individual
Prefix:MR
First Name:LAURENCE
Middle Name:L
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 1:312 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829-2730
Mailing Address - Country:US
Mailing Address - Phone:662-340-1138
Mailing Address - Fax:662-728-5185
Practice Address - Street 1:202 N 1ST ST
Practice Address - Street 2:STE A
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829-2718
Practice Address - Country:US
Practice Address - Phone:662-340-1138
Practice Address - Fax:662-728-5185
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13641207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00112220Medicaid
MS110001737Medicare ID - Type Unspecified
MS00112220Medicaid