Provider Demographics
NPI:1124259668
Name:JUSTIN FERGUSON, D.D.S., PC
Entity type:Organization
Organization Name:JUSTIN FERGUSON, D.D.S., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:WARREN
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:276-889-5141
Mailing Address - Street 1:PO BOX 2518
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:VA
Mailing Address - Zip Code:24266-2518
Mailing Address - Country:US
Mailing Address - Phone:276-889-5141
Mailing Address - Fax:276-889-0770
Practice Address - Street 1:138 HIGHLANDS DRIVE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:VA
Practice Address - Zip Code:24266
Practice Address - Country:US
Practice Address - Phone:276-889-5141
Practice Address - Fax:276-889-0770
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BALL & FERGUSON DENTISTRY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-31
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401-4109231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9177664Medicaid