Provider Demographics
NPI:1174579924
Name:BULLEN, DENNIS M (CRNA)
Entity type:Individual
Prefix:MR
First Name:DENNIS
Middle Name:M
Last Name:BULLEN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12525 SPRINGFIELD RD
Mailing Address - Street 2:
Mailing Address - City:NEW SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44443-9783
Mailing Address - Country:US
Mailing Address - Phone:330-549-9456
Mailing Address - Fax:
Practice Address - Street 1:2793 SHAWNEE RD
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45806-1444
Practice Address - Country:US
Practice Address - Phone:419-227-8209
Practice Address - Fax:419-222-6007
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN204525367500000X
OHCOA 02041-NA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0950707Medicaid
041281OtherAANA NO.
PA1022890730001Medicaid
OH0950707Medicaid
PA091325Medicare PIN