Provider Demographics
NPI:1356705396
Name:POTABENKO, DENNIS (HIS)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:
Last Name:POTABENKO
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5640 W BROADWAY AVE STE B
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55428-3567
Mailing Address - Country:US
Mailing Address - Phone:763-533-5722
Mailing Address - Fax:763-533-5654
Practice Address - Street 1:5640 W BROADWAY AVE STE B
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55428-3567
Practice Address - Country:US
Practice Address - Phone:763-533-5722
Practice Address - Fax:763-533-5654
Is Sole Proprietor?:No
Enumeration Date:2016-04-06
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2778237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist