Provider Demographics
NPI:1952429946
Name:WEITZ, DUSTIN FREDERICK (DDS, MS)
Entity Type:Individual
Prefix:MR
First Name:DUSTIN
Middle Name:FREDERICK
Last Name:WEITZ
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 S MOUNTAIN VIEW RD STE 4
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-9205
Mailing Address - Country:US
Mailing Address - Phone:208-882-2986
Mailing Address - Fax:208-882-2987
Practice Address - Street 1:505 S MOUNTAIN VIEW RD STE 4
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-9205
Practice Address - Country:US
Practice Address - Phone:208-882-2986
Practice Address - Fax:208-882-2987
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2020-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13926122300000X
IDD-3556-EN1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806107300Medicaid