Healthcare Provider Details

I. General information

NPI: 1487645537
Provider Name (Legal Business Name): JON E DENNIS MD, MPH, FAAP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 CENTRACARE CIR SUITE #1300
SAINT CLOUD MN
56303-5000
US

IV. Provider business mailing address

1900 CENTRACARE CIR SUITE #1300
SAINT CLOUD MN
56303-5000
US

V. Phone/Fax

Practice location:
  • Phone: 320-654-3630
  • Fax: 320-654-3657
Mailing address:
  • Phone: 320-654-3630
  • Fax: 320-654-3657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number24057
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: