Healthcare Provider Details

I. General information

NPI: 1750141842
Provider Name (Legal Business Name): JAMES CLIFTON DENNIS IDMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2024
Last Update Date: 03/19/2024
Certification Date: 03/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LACKLAND AFB TEXAS
APO AA
78234
US

IV. Provider business mailing address

7914 RAY BON DR APT 1514
SAN ANTONIO TX
78218-2154
US

V. Phone/Fax

Practice location:
  • Phone: 507-412-9838
  • Fax:
Mailing address:
  • Phone: 507-412-9838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: