Provider Demographics
NPI:1114431939
Name:MCMINN, DUSTIN JACOB (HAS)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:JACOB
Last Name:MCMINN
Suffix:
Gender:M
Credentials:HAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-2208
Mailing Address - Country:US
Mailing Address - Phone:909-262-7027
Mailing Address - Fax:
Practice Address - Street 1:302 E 4TH ST
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-2208
Practice Address - Country:US
Practice Address - Phone:909-262-7027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-01
Last Update Date:2018-03-17
Deactivation Date:2017-12-01
Deactivation Code:
Reactivation Date:2017-12-08
Provider Licenses
StateLicense IDTaxonomies
OR10181198237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist