Provider Demographics
NPI:1619661980
Name:FIELDS, JUSTIN (DMD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:FIELDS
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 1:2103 59TH ST W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-7015
Mailing Address - Country:US
Mailing Address - Phone:941-792-2766
Mailing Address - Fax:
Practice Address - Street 1:7305 N MILITARY TRL
Practice Address - Street 2:
Practice Address - City:RIVIERA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33410-7417
Practice Address - Country:US
Practice Address - Phone:561-422-8262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-08
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN27793122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist