Provider Demographics
NPI:1699103572
Name:LAPOULAS, JUSTINA MARIE (DMD, MS)
Entity type:Individual
Prefix:
First Name:JUSTINA
Middle Name:MARIE
Last Name:LAPOULAS
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:JUSTINA
Other - Middle Name:MARIE
Other - Last Name:D'AGOSTINI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:432 S WASHINGTON AVE
Mailing Address - Street 2:UNIT #1301
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-3854
Mailing Address - Country:US
Mailing Address - Phone:248-469-2724
Mailing Address - Fax:
Practice Address - Street 1:432 S WASHINGTON AVE
Practice Address - Street 2:UNIT #1301
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-3854
Practice Address - Country:US
Practice Address - Phone:248-469-2724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-31
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901020861122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist