Healthcare Provider Details

I. General information

NPI: 1174579924
Provider Name (Legal Business Name): DENNIS M BULLEN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 10/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2793 SHAWNEE RD
LIMA OH
45806-1444
US

IV. Provider business mailing address

12525 SPRINGFIELD RD
NEW SPRINGFIELD OH
44443-9783
US

V. Phone/Fax

Practice location:
  • Phone: 419-227-8209
  • Fax: 419-222-6007
Mailing address:
  • Phone: 330-549-9456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN204525
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCOA 02041-NA
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: