Provider Demographics
NPI:1356652184
Name:SHORT, JUSTIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:SHORT
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 1:395 E CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MO
Mailing Address - Zip Code:63379-1405
Mailing Address - Country:US
Mailing Address - Phone:636-462-8599
Mailing Address - Fax:636-462-8597
Practice Address - Street 1:395 E CHERRY ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MO
Practice Address - Zip Code:63379-1405
Practice Address - Country:US
Practice Address - Phone:636-462-8599
Practice Address - Fax:636-462-8597
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-26
Last Update Date:2010-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005026026122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist