Provider Demographics
NPI:1548796527
Name:DUTSON, DEREK J (DMD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:J
Last Name:DUTSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 SW PANNER ST
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-6463
Mailing Address - Country:US
Mailing Address - Phone:435-864-7168
Mailing Address - Fax:
Practice Address - Street 1:90 HOPE DR
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME AFB
Practice Address - State:ID
Practice Address - Zip Code:83648
Practice Address - Country:US
Practice Address - Phone:208-828-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10337490-99221223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist