Provider Demographics
NPI:1043369101
Name:JUSTIN B SHORT DMD PC
Entity Type:Organization
Organization Name:JUSTIN B SHORT DMD PC
Other - Org Name:LINCOLN COUNTY DENTAL LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:BRYAN
Authorized Official - Last Name:SHORT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:314-406-8202
Mailing Address - Street 1:395 E CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MO
Mailing Address - Zip Code:63379
Mailing Address - Country:US
Mailing Address - Phone:636-462-8599
Mailing Address - Fax:636-462-8597
Practice Address - Street 1:395 E CHERRY ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MO
Practice Address - Zip Code:63379
Practice Address - Country:US
Practice Address - Phone:636-462-8599
Practice Address - Fax:636-462-8597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005026026122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty