Provider Demographics
NPI:1922187483
Name:DENNY, M L (OD)
Entity Type:Individual
Prefix:
First Name:M
Middle Name:L
Last Name:DENNY
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:PO BOX 1419
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:SC
Mailing Address - Zip Code:29560-1419
Mailing Address - Country:US
Mailing Address - Phone:843-374-5487
Mailing Address - Fax:843-374-7342
Practice Address - Street 1:123 EPPS ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:SC
Practice Address - Zip Code:29560
Practice Address - Country:US
Practice Address - Phone:843-374-5487
Practice Address - Fax:843-374-7342
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC495152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD04957Medicaid
SC0643520001Medicare NSC
U21527Medicare UPIN