Provider Demographics
NPI:1619648011
Name:KINNEY, DUSTIN BENTLEY (IDHS)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:BENTLEY
Last Name:KINNEY
Suffix:
Gender:M
Credentials:IDHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9235 GROUPER RD
Mailing Address - Street 2:
Mailing Address - City:CAPE CANAVERAL
Mailing Address - State:FL
Mailing Address - Zip Code:32920-4402
Mailing Address - Country:US
Mailing Address - Phone:937-214-4153
Mailing Address - Fax:
Practice Address - Street 1:9235 GROUPER RD
Practice Address - Street 2:
Practice Address - City:CAPE CANAVERAL
Practice Address - State:FL
Practice Address - Zip Code:32920-4402
Practice Address - Country:US
Practice Address - Phone:937-214-4153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-24
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman