Healthcare Provider Details

I. General information

NPI: 1528666328
Provider Name (Legal Business Name): DUSTIN LEE DUNN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2020
Last Update Date: 01/07/2021
Certification Date: 01/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 MEDICAL PARK RD
COLUMBIA SC
29203-6808
US

IV. Provider business mailing address

PO BOX 743904
ATLANTA GA
30374-3904
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-8800
  • Fax: 803-434-8802
Mailing address:
  • Phone: 803-296-7320
  • Fax: 803-296-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: