Provider Demographics
NPI:1861272080
Name:UTT, DENNIS RUSSELL
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:RUSSELL
Last Name:UTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3625 ORCHARD ST
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-4550
Mailing Address - Country:US
Mailing Address - Phone:330-853-0632
Mailing Address - Fax:
Practice Address - Street 1:3625 ORCHARD ST
Practice Address - Street 2:
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062-4550
Practice Address - Country:US
Practice Address - Phone:330-853-0632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-04
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1821206228WVMedicaid
WV1356607394Medicaid
WV125553494Medicaid