Healthcare Provider Details

I. General information

NPI: 1669009791
Provider Name (Legal Business Name): DUSTIN THEIS DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2020
Last Update Date: 04/17/2025
Certification Date: 04/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1580 CREEKSIDE DR STE 100
FOLSOM CA
95630-3887
US

IV. Provider business mailing address

5120 MANZANITA AVE STE 100
CARMICHAEL CA
95608-0590
US

V. Phone/Fax

Practice location:
  • Phone: 916-961-3434
  • Fax:
Mailing address:
  • Phone: 916-947-6792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number5979
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number5979
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: