Provider Demographics
NPI:1417114844
Name:GRIFFIN, JUSTIN WALLACE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:WALLACE
Last Name:GRIFFIN
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 1:5 ABBEYHILL CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-7423
Mailing Address - Country:US
Mailing Address - Phone:803-462-0092
Mailing Address - Fax:803-788-0099
Practice Address - Street 1:10136 TWO NOTCH RD
Practice Address - Street 2:SUITE 5
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229-4389
Practice Address - Country:US
Practice Address - Phone:803-788-0099
Practice Address - Fax:803-788-0040
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC37701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice