Provider Demographics
NPI:1275592040
Name:KATSUR, JUSTIN J (DMD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:J
Last Name:KATSUR
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 1:926 GREAT POND DR
Mailing Address - Street 2:SUITE 2003
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-7244
Mailing Address - Country:US
Mailing Address - Phone:407-772-5124
Mailing Address - Fax:407-788-3572
Practice Address - Street 1:3727 N GOLDENROD RD
Practice Address - Street 2:SUITE 108
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-8611
Practice Address - Country:US
Practice Address - Phone:407-671-0001
Practice Address - Fax:407-671-3496
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN163721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000361000Medicaid