Provider Demographics
NPI:1750013306
Name:JUSTICE, KATIE L (DENTAL HYGENIST)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:L
Last Name:JUSTICE
Suffix:
Gender:F
Credentials:DENTAL HYGENIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 SOUTHLAND DR
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-4403
Mailing Address - Country:US
Mailing Address - Phone:573-471-4167
Mailing Address - Fax:573-471-4212
Practice Address - Street 1:220 SOUTHLAND DR
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-4403
Practice Address - Country:US
Practice Address - Phone:573-471-4167
Practice Address - Fax:573-471-4212
Is Sole Proprietor?:No
Enumeration Date:2022-06-30
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018032823124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist