Healthcare Provider Details

I. General information

NPI: 1760328884
Provider Name (Legal Business Name): JUSTIN K MACK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10377 INDUSTRIAL BLVD NE
COVINGTON GA
30014-1403
US

IV. Provider business mailing address

4256 TILLY MILL RD APT 2415
DORAVILLE GA
30360-3282
US

V. Phone/Fax

Practice location:
  • Phone: 770-222-2322
  • Fax:
Mailing address:
  • Phone: 901-834-2166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN124374
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: