MEDICARE: GREGORY BRENT DENNIS PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	PY0312	NV

General Provider Information

NPI Number	:	1972562221
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY BRENT DENNIS PHD

Provider Business Mailing Address
First Line	:	PMB 101 # 115
Second Line	:	806 BUCHANAN AVE
City	:	BOULDER CITY
State	:	NV
Zip	:	89005
Country	:	US
Telephone Number	:	702-293-5946
Fax Number	:	702-293-5168

Provider Business Practice Location Address
First Line	:	1000 NEVADA HWY
Second Line	:	SUITE 106
City	:	BOULDER CITY
State	:	NV
Zip	:	89005-1813
Country	:	US
Telephone Number	:	702-293-5945
Fax Number	:	702-293-5168

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/23/2006
Last Update Date	:	10/23/2007

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