Provider Demographics
NPI:1194930214
Name:KABACZY, DENNIS W (PA)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:W
Last Name:KABACZY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47311 FIVE MILE RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-3768
Mailing Address - Country:US
Mailing Address - Phone:734-254-0665
Mailing Address - Fax:734-254-0667
Practice Address - Street 1:47311 FIVE MILE RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-3768
Practice Address - Country:US
Practice Address - Phone:734-254-0665
Practice Address - Fax:734-254-0667
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002105363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP50736Medicare UPIN