Healthcare Provider Details

I. General information

NPI: 1578774022
Provider Name (Legal Business Name): DUSTIN DALE DINNING DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 08/25/2023
Certification Date: 08/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3815 N SCHREIBER WAY STE 101
COEUR D ALENE ID
83815-8362
US

IV. Provider business mailing address

3815 N SCHREIBER WAY STE 101
COEUR D ALENE ID
83815-8362
US

V. Phone/Fax

Practice location:
  • Phone: 208-758-0920
  • Fax: 208-765-0277
Mailing address:
  • Phone: 208-755-2804
  • Fax: 208-765-0277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberO-0663
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: