Provider Demographics
NPI:1093448565
Name:MCBRIDE, JUSTIN (DMD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:MCBRIDE
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 1:12341 SW ARABELLA DR
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-7728
Mailing Address - Country:US
Mailing Address - Phone:903-399-4681
Mailing Address - Fax:
Practice Address - Street 1:1679 NW SAINT LUCIE WEST BLVD
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-2106
Practice Address - Country:US
Practice Address - Phone:772-224-3090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-02
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FL283881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program