Provider Demographics
NPI:1235445297
Name:VANCE, DUSTIN (OD)
Entity Type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:
Last Name:VANCE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3150 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72501-7515
Mailing Address - Country:US
Mailing Address - Phone:870-793-6544
Mailing Address - Fax:
Practice Address - Street 1:3150 HARRISON ST
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:AR
Practice Address - Zip Code:72501-7515
Practice Address - Country:US
Practice Address - Phone:870-793-6544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-27
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2657152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR187164722Medicaid
5G795Medicare PIN