Provider Demographics
NPI:1225264039
Name:PRATT, JUSTIN W (DMD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:W
Last Name:PRATT
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 1:830 S MAYO TRL
Mailing Address - Street 2:
Mailing Address - City:PAINTSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41240-1384
Mailing Address - Country:US
Mailing Address - Phone:606-372-5000
Mailing Address - Fax:606-349-5123
Practice Address - Street 1:830 S MAYO TRL
Practice Address - Street 2:
Practice Address - City:PAINTSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41240-1384
Practice Address - Country:US
Practice Address - Phone:606-372-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-08
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY8756122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist