Provider Demographics
NPI:1821635392
Name:JUSTICE DENTAL GEORGETOWN DBA THOMPSON FAMILY DENTAL
Entity Type:Organization
Organization Name:JUSTICE DENTAL GEORGETOWN DBA THOMPSON FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CLAYCOMB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-868-5999
Mailing Address - Street 1:203 CHAMPION WAY STE 6
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-8861
Mailing Address - Country:US
Mailing Address - Phone:502-868-6999
Mailing Address - Fax:502-868-5944
Practice Address - Street 1:203 CHAMPION WAY STE 6
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-8861
Practice Address - Country:US
Practice Address - Phone:502-868-6999
Practice Address - Fax:502-868-5944
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JUSTICE DENTAL GEORGETOWN DBA THOMPSON FAMILY DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-12-04
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty