Provider Demographics
NPI:1619323243
Name:JUSTICE, NATHAN
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:JUSTICE
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 1:9420 DAYTON LEBANON PIKE
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45458-3860
Mailing Address - Country:US
Mailing Address - Phone:937-433-8900
Mailing Address - Fax:
Practice Address - Street 1:29001 CEDAR RD STE 660
Practice Address - Street 2:
Practice Address - City:LYNDHURST
Practice Address - State:OH
Practice Address - Zip Code:44124-4041
Practice Address - Country:US
Practice Address - Phone:440-461-8200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-12
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.24744122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist