Provider Demographics
NPI:1962533232
Name:DAVIS, DENNIS WAYNE SR (OPTICIAN)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:WAYNE
Last Name:DAVIS
Suffix:SR
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 HAMPSTEAD STATION
Mailing Address - Street 2:US HWY 17
Mailing Address - City:HAMPSTEAD
Mailing Address - State:NC
Mailing Address - Zip Code:28443-2149
Mailing Address - Country:US
Mailing Address - Phone:910-270-3249
Mailing Address - Fax:910-270-3249
Practice Address - Street 1:HAMPSTEAD STATION 11
Practice Address - Street 2:US HWY 17
Practice Address - City:HAMPSTEAD
Practice Address - State:NC
Practice Address - Zip Code:28443
Practice Address - Country:US
Practice Address - Phone:910-270-3249
Practice Address - Fax:910-270-3249
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC524156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8802053Medicaid
NC8802053Medicaid