Healthcare Provider Details

I. General information

NPI: 1548617111
Provider Name (Legal Business Name): HENRY DUST MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2016
Last Update Date: 07/29/2022
Certification Date: 07/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3304 COOLEY CT
PORTAGE MI
49024-7430
US

IV. Provider business mailing address

1500 E MEDICAL CENTER DR TC 3116
ANN ARBOR MI
48109
US

V. Phone/Fax

Practice location:
  • Phone: 269-349-2266
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301109403
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number4301507505
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: