Provider Demographics
NPI:1750352902
Name:MCENTAFFER, DENNIS J (PT)
Entity type:Individual
Prefix:MR
First Name:DENNIS
Middle Name:J
Last Name:MCENTAFFER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1512 SERVICE DR
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987-3803
Mailing Address - Country:US
Mailing Address - Phone:507-474-6900
Mailing Address - Fax:507-474-0502
Practice Address - Street 1:1512 SERVICE DR
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987-3803
Practice Address - Country:US
Practice Address - Phone:507-474-6900
Practice Address - Fax:507-474-0502
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5704225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN839662100Medicaid
MN839662100Medicaid