Provider Demographics
NPI:1962503615
Name:RISTON, DENNIS DE KOVEN (MD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:DE KOVEN
Last Name:RISTON
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 1:768 SOUTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:TX
Mailing Address - Zip Code:77657
Mailing Address - Country:US
Mailing Address - Phone:409-781-1920
Mailing Address - Fax:
Practice Address - Street 1:768 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:TX
Practice Address - Zip Code:77657
Practice Address - Country:US
Practice Address - Phone:409-781-1920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA05207R207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1339598Medicaid
LA1339598Medicaid
LAB25952Medicare UPIN