Provider Demographics
NPI:1851812267
Name:DILTS-WALDROP, DENISE
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:DILTS-WALDROP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4626 SHASTA DAM BLVD
Mailing Address - Street 2:
Mailing Address - City:SHASTA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:96019-9414
Mailing Address - Country:US
Mailing Address - Phone:530-275-0866
Mailing Address - Fax:530-275-8596
Practice Address - Street 1:4626 SHASTA DAM BLVD
Practice Address - Street 2:
Practice Address - City:SHASTA LAKE
Practice Address - State:CA
Practice Address - Zip Code:96019-9414
Practice Address - Country:US
Practice Address - Phone:530-275-0866
Practice Address - Fax:530-275-8596
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASL5482156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician