Healthcare Provider Details

I. General information

NPI: 1013908961
Provider Name (Legal Business Name): VICKIE L DENNIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 10/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 JEFFERSON ST NORTH
WADENA MN
56482-1296
US

IV. Provider business mailing address

415 JEFFERSON ST NORTH
WADENA MN
56482-1296
US

V. Phone/Fax

Practice location:
  • Phone: 218-631-3510
  • Fax: 218-631-7507
Mailing address:
  • Phone: 218-631-3510
  • Fax: 218-631-7507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number29545
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: