Healthcare Provider Details

I. General information

NPI: 1568038693
Provider Name (Legal Business Name): SEAN COURTNEY DENNIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2021
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2929 E CAMELBACK RD STE 110
PHOENIX AZ
85016-4425
US

IV. Provider business mailing address

32713 N 19TH LN
PHOENIX AZ
85085-7266
US

V. Phone/Fax

Practice location:
  • Phone: 602-599-0132
  • Fax:
Mailing address:
  • Phone: 253-985-0396
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number002525
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: