Provider Demographics
NPI:1174824619
Name:JUSTIN CHURCH DMD PLC
Entity Type:Organization
Organization Name:JUSTIN CHURCH DMD PLC
Other - Org Name:YUMA DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHURCH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:480-206-0139
Mailing Address - Street 1:2540 S 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-7286
Mailing Address - Country:US
Mailing Address - Phone:928-344-5700
Mailing Address - Fax:928-344-3645
Practice Address - Street 1:2540 S 4TH AVE
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-7286
Practice Address - Country:US
Practice Address - Phone:928-344-5700
Practice Address - Fax:928-344-3645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-16
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7892261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental