Provider Demographics
NPI:1194938373
Name:INGRAM, DENNIS ALAN (STATE LICENSED OPTIC)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:ALAN
Last Name:INGRAM
Suffix:
Gender:M
Credentials:STATE LICENSED OPTIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:828 CRYSTAL VIEW DR
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:AZ
Mailing Address - Zip Code:85344
Mailing Address - Country:US
Mailing Address - Phone:928-667-3153
Mailing Address - Fax:
Practice Address - Street 1:1317 JOSHUA AVE
Practice Address - Street 2:SUITE H
Practice Address - City:PARKER
Practice Address - State:AZ
Practice Address - Zip Code:85344
Practice Address - Country:US
Practice Address - Phone:928-669-6971
Practice Address - Fax:928-669-8901
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1140156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician