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General NPI Number Information
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NPI Number | 1881258408
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Entity Type | Individual
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Provider Name | DR. JUSTIN DO
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Gender | Male
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Dates
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Enumeration Date | 04/29/2019
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Last Update Date | 10/19/2021
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Provider Practice Location Address
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Address Line | 14007 MINNIEVILLE RD
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City | WOODBRIDGE
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State | VA
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Zip | 22193-2310
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Country | US
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Telephone | 703-670-5414
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Fax |
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Provider Business Mailing Address
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Address Line | 12809 PILOTS LANDING WAY APT SUITE
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City | GAITHERSBURG
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State | MD
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Zip | 20878-6118
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Country | US
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Telephone | 240-644-5394
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 0401416976
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License Number State | VA
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