MEDICARE: DUSTIN DAKOTA PRINCE DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	02007373A	IN
2	207Q00000X	Family Medicine Physician	3781208	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366183790
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DUSTIN DAKOTA PRINCE DO

Provider Business Mailing Address
First Line	:	190 E BANNOCK ST
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83712-6241
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	714 N COLLEGE RD STE A
Second Line	:
City	:	TWIN FALLS
State	:	ID
Zip	:	83301-5812
Country	:	US
Telephone Number	:	208-814-5075
Fax Number	:	208-933-9660

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/07/2022
Last Update Date	:	06/03/2026

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Directions to “ DUSTIN DAKOTA PRINCE DO” Practice Location

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