Provider Demographics
NPI:1588990642
Name:JUSTIN CHURCH DMD PLC
Entity type:Organization
Organization Name:JUSTIN CHURCH DMD PLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHURCH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:480-206-0139
Mailing Address - Street 1:550 W 16TH ST
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-4632
Mailing Address - Country:US
Mailing Address - Phone:928-782-0289
Mailing Address - Fax:928-782-0289
Practice Address - Street 1:550 W 16TH ST
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-4632
Practice Address - Country:US
Practice Address - Phone:928-782-0289
Practice Address - Fax:928-782-0289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-26
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7892261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental