Provider Demographics
NPI:1013264423
Name:CUSTODIO, DENNIS BUENAVENTURA (INDEPENDENT DUTY HM)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:BUENAVENTURA
Last Name:CUSTODIO
Suffix:
Gender:M
Credentials:INDEPENDENT DUTY HM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6910 227TH STREET CT E
Mailing Address - Street 2:
Mailing Address - City:SPANAWAY
Mailing Address - State:WA
Mailing Address - Zip Code:98387-5841
Mailing Address - Country:US
Mailing Address - Phone:253-905-8239
Mailing Address - Fax:
Practice Address - Street 1:69 TROUT AVE
Practice Address - Street 2:NAVAL UNDERSEA MEDICAL INSTITUTE
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06349
Practice Address - Country:US
Practice Address - Phone:253-905-8239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-06
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman