Provider Demographics
NPI:1265038228
Name:JUSTUS, ELLEN E (DMD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:E
Last Name:JUSTUS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 WINTHROP CT
Mailing Address - Street 2:
Mailing Address - City:HURON
Mailing Address - State:OH
Mailing Address - Zip Code:44839-1468
Mailing Address - Country:US
Mailing Address - Phone:419-602-3857
Mailing Address - Fax:
Practice Address - Street 1:875 WESTMORELAND AVE
Practice Address - Street 2:
Practice Address - City:NAPOLEON
Practice Address - State:OH
Practice Address - Zip Code:43545-4354
Practice Address - Country:US
Practice Address - Phone:877-216-9296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0263411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty