Healthcare Provider Details

I. General information

NPI: 1104503218
Provider Name (Legal Business Name): DUSTIN YORK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2023
Last Update Date: 08/01/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 W D.L. INGRAM AVE, BLDG 1408
CANNON AFB NM
88103-5103
US

IV. Provider business mailing address

423 SHREVEPORT RD
BARKSDALE AFB LA
71110-2049
US

V. Phone/Fax

Practice location:
  • Phone: 575-784-2778
  • Fax:
Mailing address:
  • Phone: 480-208-5809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD011918
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: