Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 1140 | AZ |
NPI | 1194938373 |
---|---|
Provider Name | Dennis Alan Ingram |
First Address | Parker, AZ 85344 |
Second Address | Parker, AZ 85344 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/05/2007 |
Last Update Date | 08/07/2007 |