Provider Demographics
NPI:1164116414
Name:CONDUFF, JUSTIN NEAL
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:NEAL
Last Name:CONDUFF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 113
Mailing Address - Street 2:
Mailing Address - City:FLOYD
Mailing Address - State:VA
Mailing Address - Zip Code:24091-0113
Mailing Address - Country:US
Mailing Address - Phone:540-745-4171
Mailing Address - Fax:
Practice Address - Street 1:103 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FLOYD
Practice Address - State:VA
Practice Address - Zip Code:24091-2380
Practice Address - Country:US
Practice Address - Phone:540-745-4171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-07
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401418441122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist