Healthcare Provider Details

I. General information

NPI: 1316468317
Provider Name (Legal Business Name): JUSTIN SOUTHWARD DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2017
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3919 N MAPLE ST
SPOKANE WA
99205-1349
US

IV. Provider business mailing address

731 N IRON BRIDGE WAY
SPOKANE WA
99202-4926
US

V. Phone/Fax

Practice location:
  • Phone: 509-444-8888
  • Fax:
Mailing address:
  • Phone: 509-444-8888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number12012755A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number70062048
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: