Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207YS0123X | Facial Plastic Surgeon | 38760 | GA |
NPI | 1215025820 |
---|---|
Provider Name | Dr. Dennis L Frew |
First Address | Fort Defiance, AZ 86504-0649 |
Second Address | Fort Defiance, AZ 86504 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/10/2006 |
Last Update Date | 08/11/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000630792A | (05) | GA |
040009455 | RR PROVIDER # (01) | GA |
E07291 | (02) | GA |