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General NPI Number Information
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NPI Number | 1588990642
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Entity Type | Organization
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Legal Business Name | JUSTIN CHURCH DMD PLC
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Dates
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Enumeration Date | 10/26/2009
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Last Update Date | 11/04/2010
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Provider Practice Location Address
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Address Line | 550 W 16TH ST
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City | YUMA
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State | AZ
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Zip | 85364-4632
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Country | US
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Telephone | 928-782-0289
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Fax | 928-782-0289
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Provider Business Mailing Address
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Address Line | 550 W 16TH ST
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City | YUMA
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State | AZ
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Zip | 85364-4632
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Country | US
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Telephone | 928-782-0289
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Fax | 928-782-0289
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Authorized Official
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Title or Position | DENTIST
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Name | DR. JUSTIN CHURCH
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Credential | DMD
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Telephone | 480-206-0139
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 7892
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License Number State | AZ
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