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General NPI Number Information
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NPI Number | 1851531289
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Entity Type | Individual
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Provider Name | JUSTIN MORONI DAZLEY M.D.
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Gender | Male
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Dates
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Enumeration Date | 02/25/2009
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Last Update Date | 06/03/2025
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Provider Practice Location Address
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Address Line | 738 N COLLEGE RD SUITE A
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City | TWIN FALLS
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State | ID
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Zip | 83301-3385
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Country | US
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Telephone | 208-814-7000
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Fax | 208-734-7294
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Provider Business Mailing Address
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Address Line | PO BOX 587
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City | TWIN FALLS
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State | ID
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Zip | 83303-0587
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Country | US
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Telephone | 208-814-7400
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Fax | 208-814-7491
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207XS0117X
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Taxonomy Name | Orthopaedic Surgery of the Spine Physician
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License Number | M-11685
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | M11685
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License Number State | ID
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