Provider Demographics
NPI:1710681028
Name:BELK, JUSTIN D (DDS)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:D
Last Name:BELK
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 1:746 S 1325 W
Mailing Address - Street 2:
Mailing Address - City:PINGREE
Mailing Address - State:ID
Mailing Address - Zip Code:83262-1321
Mailing Address - Country:US
Mailing Address - Phone:208-680-7767
Mailing Address - Fax:
Practice Address - Street 1:1236 BOND AVE
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-3503
Practice Address - Country:US
Practice Address - Phone:208-356-5439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-29
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-5518122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist