Provider Demographics
NPI:1225523582
Name:PENNINGTON, JUSTIN PAUL (DMD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:PAUL
Last Name:PENNINGTON
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 1:120 LONGLEAF CIR
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-9388
Mailing Address - Country:US
Mailing Address - Phone:678-559-5353
Mailing Address - Fax:
Practice Address - Street 1:28 BUTLER ST
Practice Address - Street 2:
Practice Address - City:MIDWAY
Practice Address - State:GA
Practice Address - Zip Code:31320-4294
Practice Address - Country:US
Practice Address - Phone:912-880-2288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0157061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice