Provider Demographics
NPI:1376157370
Name:SUGGS, JUSTIN CLAYTON
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:CLAYTON
Last Name:SUGGS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1511 N TUXEDO ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46201-1475
Mailing Address - Country:US
Mailing Address - Phone:219-331-8099
Mailing Address - Fax:
Practice Address - Street 1:3101 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-3966
Practice Address - Country:US
Practice Address - Phone:765-662-1022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-07
Last Update Date:2020-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013487A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist