Provider Demographics
NPI:1164434742
Name:NELSON, JUSTIN MARCUS (DMD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:MARCUS
Last Name:NELSON
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 1:577 STERNBERG AVE
Mailing Address - Street 2:USA DENTAC
Mailing Address - City:FT EUSTIS
Mailing Address - State:VA
Mailing Address - Zip Code:23604-5311
Mailing Address - Country:US
Mailing Address - Phone:757-314-7944
Mailing Address - Fax:575-314-7942
Practice Address - Street 1:577 STERNBERG AVE
Practice Address - Street 2:USA DENTAC
Practice Address - City:FT EUSTIS
Practice Address - State:VA
Practice Address - Zip Code:23604-5311
Practice Address - Country:US
Practice Address - Phone:757-314-7944
Practice Address - Fax:757-314-7942
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX228551223E0200X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist