MEDICARE: JUSTIN PHILIP DMD

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	122300000X	Dentist	DN123234	GA

General Provider Information

NPI Number	:	1699458182
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTIN PHILIP DMD

Provider Business Mailing Address
First Line	:	1261 WOODLAND VIEW RD
Second Line	:
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30043-7513
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3490 PIEDMONT RD NE STE 230
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30305-4810
Country	:	US
Telephone Number	:	404-233-4900
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/10/2023
Last Update Date	:	08/10/2023

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Directions to “ JUSTIN PHILIP DMD” Practice Location

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