Healthcare Provider Details

I. General information

NPI: 1104400928
Provider Name (Legal Business Name): JUSTIN P LIGGETT DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2021
Last Update Date: 09/23/2021
Certification Date: 09/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

765 MORNING STAR DR
SONORA CA
95370-5193
US

IV. Provider business mailing address

765 MORNING STAR DR
SONORA CA
95370-5193
US

V. Phone/Fax

Practice location:
  • Phone: 209-532-7418
  • Fax: 209-533-3515
Mailing address:
  • Phone: 209-532-7418
  • Fax: 209-533-3515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JUSTIN PAGE LIGGETT
Title or Position: DENTIST
Credential: DDS
Phone: 209-532-7418