Provider Demographics
NPI:1972276368
Name:MCDONALD, DENNIS D
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:D
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:436 N 17TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64501-2015
Mailing Address - Country:US
Mailing Address - Phone:816-233-7060
Mailing Address - Fax:
Practice Address - Street 1:436 N 17TH ST
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64501-2015
Practice Address - Country:US
Practice Address - Phone:816-233-7060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-30
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO048381310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility