Provider Demographics
NPI:1497115752
Name:TULLIS, JUSTIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:TULLIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 E FONTANERO ST STE 307
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-7526
Mailing Address - Country:US
Mailing Address - Phone:719-475-9023
Mailing Address - Fax:719-475-9009
Practice Address - Street 1:320 E FONTANERO ST STE 307
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-7526
Practice Address - Country:US
Practice Address - Phone:719-475-9023
Practice Address - Fax:719-475-9009
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-01
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO390200000X
CO2042561223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO204256OtherDENTAL LICENSE NUMBER