Healthcare Provider Details

I. General information

NPI: 1073945788
Provider Name (Legal Business Name): JUSTIN M HOAG DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2013
Last Update Date: 05/03/2021
Certification Date: 05/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

477 VIKING DR STE 190US
VIRGINIA BEACH VA
23452-7349
US

IV. Provider business mailing address

351 WEST 6TH ST. US ARMY DENTAL ACTIVITY ATTN: NANCY POSEY-EDWARDS
FORT STEWART GA
31314-4704
US

V. Phone/Fax

Practice location:
  • Phone: 757-486-8611
  • Fax:
Mailing address:
  • Phone: 912-767-6735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401414134
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: