Provider Demographics
NPI:1477018653
Name:KILPATRICK, DUSTIN WINSTON
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:WINSTON
Last Name:KILPATRICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 CALLE FIERROS
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-3034
Mailing Address - Country:US
Mailing Address - Phone:559-284-9106
Mailing Address - Fax:
Practice Address - Street 1:16250 SAND CANYON AVE
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3714
Practice Address - Country:US
Practice Address - Phone:949-727-5016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-01
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
157364246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist