Provider Demographics
NPI:1316901952
Name:KANTOR, DENNIS REID (OD)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:REID
Last Name:KANTOR
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 E MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7121
Mailing Address - Country:US
Mailing Address - Phone:541-772-5504
Mailing Address - Fax:
Practice Address - Street 1:820 E MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7121
Practice Address - Country:US
Practice Address - Phone:541-772-5504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-12
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1353AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR154864Medicaid
OR0755080001Medicare NSC
ORT67770Medicare UPIN
R0000JHDTCMedicare ID - Type Unspecified