Healthcare Provider Details

I. General information

NPI: 1588173728
Provider Name (Legal Business Name): JACOB D JUSTICE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2017
Last Update Date: 01/06/2021
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 PARK AVE NE
NORTON VA
24273-1009
US

IV. Provider business mailing address

PO BOX 1500
ELKHORN CITY KY
41522
US

V. Phone/Fax

Practice location:
  • Phone: 276-679-6030
  • Fax: 276-325-0459
Mailing address:
  • Phone: 606-754-0155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10032
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401416829
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: