Healthcare Provider Details

I. General information

NPI: 1619661980
Provider Name (Legal Business Name): JUSTIN FIELDS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2023
Last Update Date: 06/08/2023
Certification Date: 05/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7305 N MILITARY TRL
RIVIERA BEACH FL
33410-7417
US

IV. Provider business mailing address

2103 59TH ST W
BRADENTON FL
34209-7015
US

V. Phone/Fax

Practice location:
  • Phone: 561-422-8262
  • Fax:
Mailing address:
  • Phone: 941-792-2766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN27793
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: