Provider Demographics
NPI:1336211325
Name:MINCH, DUSTIN L (LMT)
Entity Type:Individual
Prefix:MR
First Name:DUSTIN
Middle Name:L
Last Name:MINCH
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 CENTENNIAL BLVD STE 5
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-3378
Mailing Address - Country:US
Mailing Address - Phone:541-521-6655
Mailing Address - Fax:
Practice Address - Street 1:1717 CENTENNIAL BLVD STE 5
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-3378
Practice Address - Country:US
Practice Address - Phone:541-521-6655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7429174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist