MEDICARE: ELKHORN DENTAL PSC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1467010629
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELKHORN DENTAL PSC

Provider Business Mailing Address
First Line	:	PO BOX 1500
Second Line	:
City	:	ELKHORN CITY
State	:	KY
Zip	:	41522-1500
Country	:	US
Telephone Number	:	606-754-0155
Fax Number	:	606-754-0151

Provider Business Practice Location Address
First Line	:	155 E MAIN ST
Second Line	:
City	:	ELKHORN CITY
State	:	KY
Zip	:	41522-9043
Country	:	US
Telephone Number	:	606-754-0155
Fax Number	:	606-754-0151

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	DR. JAMES D JUSTICE
Credential	:	DMD
Telephone Number	:	606-754-0155

Provider Enumeration Date	:	06/03/2019
Last Update Date	:	12/16/2020

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