Healthcare Provider Details

I. General information

NPI: 1477918571
Provider Name (Legal Business Name): DENNIS EARL SPAIN JR. CPT, LSN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2015
Last Update Date: 12/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N SAINT PAUL ST #310
DALLAS TX
75201-3114
US

IV. Provider business mailing address

400 N SAINT PAUL ST #310
DALLAS TX
75201-3114
US

V. Phone/Fax

Practice location:
  • Phone: 214-205-8915
  • Fax: 469-904-2740
Mailing address:
  • Phone: 214-205-8915
  • Fax: 469-904-2740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number2728294
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2728293
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: