Provider Demographics
NPI:1104291392
Name:DENNIS, MARTIN
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:DENNIS
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 1:2409 TIMBER RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75028-7503
Mailing Address - Country:US
Mailing Address - Phone:214-473-8682
Mailing Address - Fax:214-291-0816
Practice Address - Street 1:2409 TIMBER RIDGE LN
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-7503
Practice Address - Country:US
Practice Address - Phone:214-473-8682
Practice Address - Fax:214-291-0816
Is Sole Proprietor?:No
Enumeration Date:2015-12-14
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33507183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145494Medicaid
TX33507OtherSTATE PHARMACY LICENSE