Provider Demographics
NPI:1164713046
Name:BYULLER, DINA
Entity Type:Individual
Prefix:
First Name:DINA
Middle Name:
Last Name:BYULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11487 W. NIKOKAI DRIVE
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-8801
Mailing Address - Country:US
Mailing Address - Phone:907-357-4657
Mailing Address - Fax:
Practice Address - Street 1:11487 W. NIKOKAI DRIVE
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8801
Practice Address - Country:US
Practice Address - Phone:907-357-4657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-26
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1477798825Medicaid