Healthcare Provider Details

I. General information

NPI: 1891582334
Provider Name (Legal Business Name): PRINCE A DENSON V OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2025
Last Update Date: 09/04/2025
Certification Date: 09/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15301 WARREN SHINGLE RD
BEALE AFB CA
95903-1905
US

IV. Provider business mailing address

15301 WARREN SHINGLE RD
BEALE AFB CA
95903-1905
US

V. Phone/Fax

Practice location:
  • Phone: 530-634-2941
  • Fax: 530-634-4763
Mailing address:
  • Phone: 530-634-2941
  • Fax: 530-634-4713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT.0004146
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: