Provider Demographics
NPI:1528550688
Name:DURNELL, DUSTIN
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:DURNELL
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 1:17490 STATE ROAD 23
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1743
Mailing Address - Country:US
Mailing Address - Phone:574-271-9000
Mailing Address - Fax:
Practice Address - Street 1:17490 STATE ROAD 23
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1743
Practice Address - Country:US
Practice Address - Phone:574-271-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-05
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013563A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty