Provider Demographics
NPI:1629238613
Name:GATES, JUSTIN LEWIS (DDS)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:LEWIS
Last Name:GATES
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 1:1128 N MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:MARION
Mailing Address - State:VA
Mailing Address - Zip Code:24354-4299
Mailing Address - Country:US
Mailing Address - Phone:276-783-6818
Mailing Address - Fax:276-783-2263
Practice Address - Street 1:1128 N MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:MARION
Practice Address - State:VA
Practice Address - Zip Code:24354-4299
Practice Address - Country:US
Practice Address - Phone:276-783-6818
Practice Address - Fax:276-783-2263
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014121511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice