Provider Demographics
NPI:1255411302
Name:KING, DENNIS J (DC, CCSP, FACO)
Entity type:Individual
Prefix:MR
First Name:DENNIS
Middle Name:J
Last Name:KING
Suffix:
Gender:M
Credentials:DC, CCSP, FACO
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 11067
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54307-1067
Mailing Address - Country:US
Mailing Address - Phone:920-434-2221
Mailing Address - Fax:920-434-2483
Practice Address - Street 1:721 CARDINAL LN
Practice Address - Street 2:SUITE 100
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-3216
Practice Address - Country:US
Practice Address - Phone:920-434-2221
Practice Address - Fax:920-434-2483
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2312111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38840100Medicaid
WIT79165Medicare UPIN
WI38840100Medicaid