Provider Demographics
NPI:1073015517
Name:SORENSEN, JUSTIN VANCE (DMD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:VANCE
Last Name:SORENSEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10760 FARADAY DR.
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123
Mailing Address - Country:US
Mailing Address - Phone:928-322-2481
Mailing Address - Fax:
Practice Address - Street 1:4055 LINDELL BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63018
Practice Address - Country:US
Practice Address - Phone:314-535-7701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-01
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018001255122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist