Provider Demographics
NPI:1790556520
Name:DITMORE, DUSTIN J
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:J
Last Name:DITMORE
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 1:15170 N HAYDEN RD STE 6B
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-2571
Mailing Address - Country:US
Mailing Address - Phone:602-805-4877
Mailing Address - Fax:
Practice Address - Street 1:15170 N HAYDEN RD STE 6B
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-2571
Practice Address - Country:US
Practice Address - Phone:602-805-4877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-28915225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist