Provider Demographics
NPI:1316561566
Name:HUMMELGARD, JUSTIN (DDS)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:HUMMELGARD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 S 36TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-2920
Mailing Address - Country:US
Mailing Address - Phone:816-364-1186
Mailing Address - Fax:
Practice Address - Street 1:103 S 36TH ST
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-2920
Practice Address - Country:US
Practice Address - Phone:816-364-1186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-03
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS616971223G0001X
MO20200206551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice