Provider Demographics
NPI:1083479224
Name:DILLON, DUSTIN LEE
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:LEE
Last Name:DILLON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:885 TIVERTON DRIVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-0001
Mailing Address - Country:US
Mailing Address - Phone:310-825-6373
Mailing Address - Fax:
Practice Address - Street 1:885 TIVERTON DRIVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-0001
Practice Address - Country:US
Practice Address - Phone:310-825-6373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-16
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NVLL4316208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program