Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | D5385 | AZ |
N | 1223D0001X | Dental Public Health | D5385 | AZ |
NPI | 1033186556 |
---|---|
Provider Name | Dr. Justin Dutton |
First Address | Sahuarita, AZ 85629-8770 |
Second Address | Sahuarita, AZ 85629-8012 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/03/2006 |
Last Update Date | 06/02/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
582579 | (05) | AZ |
ODB23DUTTJU1 | (05) | AZ |