Provider Demographics
NPI:1992486203
Name:SERVAIS, JUSTIN MICHAEL (DMD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:MICHAEL
Last Name:SERVAIS
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 1:4702 CREEKWOOD LN APT 304
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-2482
Mailing Address - Country:US
Mailing Address - Phone:608-790-0200
Mailing Address - Fax:
Practice Address - Street 1:2830 DARLING CT
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-2754
Practice Address - Country:US
Practice Address - Phone:608-783-7330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-28
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6001314151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice