Provider Demographics
NPI:1760834980
Name:UNITED STATED NAVY
Entity Type:Organization
Organization Name:UNITED STATED NAVY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:ROGER
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-241-9192
Mailing Address - Street 1:BLDG H 2005 KNIGHT LANE
Mailing Address - Street 2:NAVY MEDICINE SUPPORT SUPPORT COMMAND ATTN: MEDICAL STA
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32212-0140
Mailing Address - Country:US
Mailing Address - Phone:760-725-3213
Mailing Address - Fax:
Practice Address - Street 1:BLDG H 2005 KNIGHT LANE
Practice Address - Street 2:NAVY MEDICINE SUPPORT SUPPORT COMMAND ATTN: MEDICAL STA
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32212-0140
Practice Address - Country:US
Practice Address - Phone:760-725-3213
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8727122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty