Healthcare Provider Details

I. General information

NPI: 1154603256
Provider Name (Legal Business Name): DENOVO PROFESSIONAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2011
Last Update Date: 09/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2603 OAK LAWN AVE SUITE 101
DALLAS TX
75219-4021
US

IV. Provider business mailing address

2603 OAK LAWN AVE SUITE 101
DALLAS TX
75219-4021
US

V. Phone/Fax

Practice location:
  • Phone: 214-219-4000
  • Fax:
Mailing address:
  • Phone: 214-219-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number552592
License Number StateTX

VIII. Authorized Official

Name: JOHN E STEVENS
Title or Position: OWNER
Credential: NP
Phone: 214-219-4000