Provider Demographics
NPI:1154634707
Name:LIDDLE, JUSTIN KIMBALL (DMD, CDT)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:KIMBALL
Last Name:LIDDLE
Suffix:
Gender:M
Credentials:DMD, CDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 S SHIELDS ST STE B1
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-1829
Mailing Address - Country:US
Mailing Address - Phone:970-224-4358
Mailing Address - Fax:970-224-4388
Practice Address - Street 1:2001 S SHIELDS ST STE B1
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-1829
Practice Address - Country:US
Practice Address - Phone:970-224-4358
Practice Address - Fax:970-224-4388
Is Sole Proprietor?:No
Enumeration Date:2010-07-23
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO101421223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics