Healthcare Provider Details

I. General information

NPI: 1467010629
Provider Name (Legal Business Name): ELKHORN DENTAL PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2019
Last Update Date: 12/16/2020
Certification Date: 12/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 E MAIN ST
ELKHORN CITY KY
41522-9043
US

IV. Provider business mailing address

PO BOX 1500
ELKHORN CITY KY
41522-1500
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 TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JAMES D JUSTICE
Title or Position: OWNER/PRESIDENT
Credential: DMD
Phone: 606-754-0155