Provider Demographics
NPI:1740741909
Name:DOVE, DUSTIN LEE (BC-HIS)
Entity Type:Individual
Prefix:MR
First Name:DUSTIN
Middle Name:LEE
Last Name:DOVE
Suffix:
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617-2937
Mailing Address - Country:US
Mailing Address - Phone:208-369-4307
Mailing Address - Fax:208-369-4503
Practice Address - Street 1:211 W MAIN ST
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-2937
Practice Address - Country:US
Practice Address - Phone:208-369-4307
Practice Address - Fax:208-369-4503
Is Sole Proprietor?:No
Enumeration Date:2019-03-28
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDHA-1961237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR10202510OtherOREGON HEALTH AUTHORITY
IDTPIDTP013943Medicaid
HA-1961OtherIDAHO BOARD OF OCCUPATIONAL LICENSING