Healthcare Provider Details

I. General information

NPI: 1366183790
Provider Name (Legal Business Name): DUSTIN DAKOTA PRINCE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2022
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 N COLLEGE RD STE A
TWIN FALLS ID
83301-5812
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-814-5075
  • Fax: 208-933-9660
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02007373A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number3781208
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: