Healthcare Provider Details

I. General information

NPI: 1639118284
Provider Name (Legal Business Name): MICKEY E. DENEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 10/20/2020
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6611 CLYO RD SUITE A
DAYTON OH
45459-2786
US

IV. Provider business mailing address

6611 CLYO RD SUITE A
DAYTON OH
45459-2786
US

V. Phone/Fax

Practice location:
  • Phone: 937-208-7300
  • Fax: 937-208-7330
Mailing address:
  • Phone: 937-208-7300
  • Fax: 937-208-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.057283
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: