Provider Demographics
NPI:1700472214
Name:BENTZ, DUSTIN
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:BENTZ
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 1:47 E APPLE BLOSSOM WAY
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:WV
Mailing Address - Zip Code:26143-5775
Mailing Address - Country:US
Mailing Address - Phone:304-580-8169
Mailing Address - Fax:
Practice Address - Street 1:47 E APPLE BLOSSOM WAY
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:WV
Practice Address - Zip Code:26143-5775
Practice Address - Country:US
Practice Address - Phone:304-580-8169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-18
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant