=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750243853
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JUSTIN P TERRY DDS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/26/2025
-----------------------------------------------------
Last Update Date | 11/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 504 WATER ST
-----------------------------------------------------
City | MANISTEE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49660-1544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-723-7957
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1783 BLAKETON DR
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49534-1702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-799-5665
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JUSTIN PARK TERRY
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 231-799-5665
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------