Provider Demographics
NPI:1639587348
Name:POULSON, JUSTIN D (DMD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:D
Last Name:POULSON
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 1:47707 JUDY LYNN LANE
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669
Mailing Address - Country:US
Mailing Address - Phone:907-283-9125
Mailing Address - Fax:907-283-9184
Practice Address - Street 1:47707 JUDY LYNN LANE
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669
Practice Address - Country:US
Practice Address - Phone:907-283-9125
Practice Address - Fax:907-283-9184
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-25
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1572122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist