=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538879648
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JUSTUS DENTAL HEALTH AND WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2022
-----------------------------------------------------
Last Update Date | 05/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 137 BROUGHTON AVE
-----------------------------------------------------
City | ANDREWS
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29510-5583
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-996-3303
-----------------------------------------------------
Fax | 866-379-9998
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1010
-----------------------------------------------------
City | KINGSTREE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29556-1010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-996-3303
-----------------------------------------------------
Fax | 866-379-9998
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. LATHONIA BENNETT
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 912-996-3303
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------