Provider Demographics
NPI:1780045427
Name:MAYNE, DUSTIN ROSS (DO)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:ROSS
Last Name:MAYNE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 DOOLITTLE DR
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH AFB
Mailing Address - State:SD
Mailing Address - Zip Code:57706-4821
Mailing Address - Country:US
Mailing Address - Phone:937-641-3000
Mailing Address - Fax:937-641-5931
Practice Address - Street 1:2900 DOOLITTLE DR
Practice Address - Street 2:
Practice Address - City:ELLSWORTH AFB
Practice Address - State:SD
Practice Address - Zip Code:57706
Practice Address - Country:US
Practice Address - Phone:937-641-3000
Practice Address - Fax:937-641-5931
Is Sole Proprietor?:No
Enumeration Date:2016-03-08
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1780208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics