Healthcare Provider Details

I. General information

NPI: 1114302825
Provider Name (Legal Business Name): JUSTIN VICE D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2015
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18944 N DALE MABRY HWY
LUTZ FL
33548-4912
US

IV. Provider business mailing address

18944 N DALE MABRY HWY
LUTZ FL
33548-4912
US

V. Phone/Fax

Practice location:
  • Phone: 813-522-5900
  • Fax:
Mailing address:
  • Phone: 616-540-2584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN25811
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: