Provider Demographics
NPI:1457616278
Name:PATRICK, DUSTIN LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:LEE
Last Name:PATRICK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:532 RAPTOR RD UNIT B
Mailing Address - Street 2:
Mailing Address - City:FRUITA
Mailing Address - State:CO
Mailing Address - Zip Code:81521-9505
Mailing Address - Country:US
Mailing Address - Phone:970-639-1500
Mailing Address - Fax:970-639-1501
Practice Address - Street 1:532 RAPTOR RD UNIT B
Practice Address - Street 2:
Practice Address - City:FRUITA
Practice Address - State:CO
Practice Address - Zip Code:81521-9505
Practice Address - Country:US
Practice Address - Phone:970-639-1500
Practice Address - Fax:970-639-1501
Is Sole Proprietor?:No
Enumeration Date:2012-07-09
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN000107641223G0001X
CO10764122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice