Provider Demographics
NPI:1104143833
Name:MOE, JUSTINE SHERYLYN (MD, DDS)
Entity type:Individual
Prefix:
First Name:JUSTINE
Middle Name:SHERYLYN
Last Name:MOE
Suffix:
Gender:F
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 OKEMOS RD
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-3200
Mailing Address - Country:US
Mailing Address - Phone:517-349-8383
Mailing Address - Fax:517-349-5566
Practice Address - Street 1:4201 OKEMOS RD
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-3200
Practice Address - Country:US
Practice Address - Phone:517-349-8383
Practice Address - Fax:517-349-5566
Is Sole Proprietor?:No
Enumeration Date:2010-04-20
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301111526208600000X, 122300000X, 1223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No122300000XDental ProvidersDentist
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery