Healthcare Provider Details

I. General information

NPI: 1225162480
Provider Name (Legal Business Name): JOHN MATTHEW DENNIS CAS REG.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2914A COLD SPRINGS RD
PLACERVILLE CA
95667-4220
US

IV. Provider business mailing address

PO BOX 221
SHINGLE SPRINGS CA
95682-0221
US

V. Phone/Fax

Practice location:
  • Phone: 530-642-1715
  • Fax: 530-642-2064
Mailing address:
  • Phone: 530-677-8029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number1838 REG.
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: