Provider Demographics
NPI:1386871747
Name:ECHOLS, JUSTIN T (DDS)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:T
Last Name:ECHOLS
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 1:509 LINDBERGH PL NE APT 722
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30324-3343
Mailing Address - Country:US
Mailing Address - Phone:404-996-7638
Mailing Address - Fax:
Practice Address - Street 1:1678 MULKEY RD STE D
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1147
Practice Address - Country:US
Practice Address - Phone:770-692-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-12
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN014237122300000X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003116346EMedicaid