Healthcare Provider Details

I. General information

NPI: 1316901952
Provider Name (Legal Business Name): DENNIS REID KANTOR O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 05/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 E MAIN ST SUITE A
MEDFORD OR
97504-7121
US

IV. Provider business mailing address

820 E MAIN ST SUITE A
MEDFORD OR
97504-7121
US

V. Phone/Fax

Practice location:
  • Phone: 541-772-5504
  • Fax:
Mailing address:
  • Phone: 541-772-5504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1353AT
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: