Provider Demographics
NPI:1285406009
Name:DENNARD, MIMI
Entity type:Individual
Prefix:
First Name:MIMI
Middle Name:
Last Name:DENNARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 CRESCENT CT
Mailing Address - Street 2:
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14225-3213
Mailing Address - Country:US
Mailing Address - Phone:716-598-4399
Mailing Address - Fax:
Practice Address - Street 1:10 CRESCENT CT
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14225-3213
Practice Address - Country:US
Practice Address - Phone:716-598-4399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-25
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY172A00000X
NY784812661172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver