Provider Demographics
NPI:1528685369
Name:MACKERT, JUSTIN (DMD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:MACKERT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15711 MADISON AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-5655
Mailing Address - Country:US
Mailing Address - Phone:440-823-3175
Mailing Address - Fax:
Practice Address - Street 1:15711 MADISON AVE STE 104
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-5655
Practice Address - Country:US
Practice Address - Phone:440-823-3175
Practice Address - Fax:216-228-7951
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-27
Last Update Date:2020-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0262151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH30.026215OtherDENTAL LICENSE