Healthcare Provider Details

I. General information

NPI: 1396891347
Provider Name (Legal Business Name): JAMES DAVID JUSTICE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 12/16/2020
Certification Date: 12/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 EAST MAIN STREET
ELKHORN CITY KY
41522
US

IV. Provider business mailing address

155 EAST MAIN STREET P.O. BOX 1500
ELKHORN CITY KY
41522
US

V. Phone/Fax

Practice location:
  • Phone: 606-754-0155
  • Fax: 606-754-0151
Mailing address:
  • Phone: 606-754-0155
  • Fax: 606-754-0151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number7265
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7265
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: