Provider Demographics
NPI:1760974117
Name:COLEMAN, JUSTINE ANNE (RDH)
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:ANNE
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:JUSTINE
Other - Middle Name:
Other - Last Name:RENDEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 SHENANGO AVE
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:PA
Mailing Address - Zip Code:16146-1503
Mailing Address - Country:US
Mailing Address - Phone:724-656-3486
Mailing Address - Fax:724-598-7337
Practice Address - Street 1:2807 WILMINGTON RD
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:PA
Practice Address - Zip Code:16105-1263
Practice Address - Country:US
Practice Address - Phone:724-656-3486
Practice Address - Fax:724-598-7337
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-01
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADH071654124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1034997540001Medicaid
PA1034997540002Medicaid