Provider Demographics
NPI:1427293448
Name:DENNIS, DUSTY K (PT)
Entity type:Individual
Prefix:
First Name:DUSTY
Middle Name:K
Last Name:DENNIS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15269 COUNTY ROAD 3610
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-1395
Mailing Address - Country:US
Mailing Address - Phone:580-371-8401
Mailing Address - Fax:580-371-8402
Practice Address - Street 1:1414 ARLINGTON ST
Practice Address - Street 2:STE 2200
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-2694
Practice Address - Country:US
Practice Address - Phone:580-371-8401
Practice Address - Fax:580-371-8402
Is Sole Proprietor?:No
Enumeration Date:2008-12-04
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2326225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100834300AMedicaid
OK100834300AMedicaid