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General NPI Number Information
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NPI Number | 1194938373
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Entity Type | Individual
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Provider Name | DENNIS ALAN INGRAM STATE LICENSED OPTIC
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Gender | Male
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Dates
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Enumeration Date | 05/07/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1317 JOSHUA AVE SUITE H
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City | PARKER
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State | AZ
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Zip | 85344
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Country | US
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Telephone | 928-669-6971
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Fax | 928-669-8901
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Provider Business Mailing Address
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Address Line | 828 CRYSTAL VIEW DR
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City | PARKER
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State | AZ
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Zip | 85344
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Country | US
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Telephone | 928-667-3153
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number | 1140
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License Number State | AZ
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