Basic Information
| Provider Information | |||||||||
| NPI: | 1497742720 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DENNIS | ||||||||
| FirstName: | R. | ||||||||
| MiddleName: | BLAKE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1106 CHUCK DAWLEY BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MOUNT PLEASANT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294644183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438491551 | ||||||||
| FaxNumber: | 8438840629 | ||||||||
| Practice Location | |||||||||
| Address1: | 1106 CHUCK DAWLEY BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MOUNT PLEASANT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294644183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438491551 | ||||||||
| FaxNumber: | 8438840629 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2005 | ||||||||
| LastUpdateDate: | 11/09/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0117X | 12163 | SC | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine |
ID Information
| ID | Type | State | Issuer | Description | DM0683 | 05 | SC | MEDICAID | GP2895 | 05 | SC | MEDICAID |