Provider Demographics
NPI:1306455720
Name:CHOW, JUSTIN J
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:J
Last Name:CHOW
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 1:12 BAY VIEW RD
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02482-4314
Mailing Address - Country:US
Mailing Address - Phone:781-733-5667
Mailing Address - Fax:
Practice Address - Street 1:171 MAINE MALL RD
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2310
Practice Address - Country:US
Practice Address - Phone:866-803-4943
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-31
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDEN4820122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist