Provider Demographics
NPI:1851573539
Name:JUSTIN BROWN DDS LLC
Entity Type:Organization
Organization Name:JUSTIN BROWN DDS LLC
Other - Org Name:PERU DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:765-473-9336
Mailing Address - Street 1:5 LOGAN ST
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IN
Mailing Address - Zip Code:46970-1642
Mailing Address - Country:US
Mailing Address - Phone:765-473-9336
Mailing Address - Fax:765-460-5743
Practice Address - Street 1:5 LOGAN ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-1642
Practice Address - Country:US
Practice Address - Phone:765-473-9336
Practice Address - Fax:765-460-5743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10988122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200864790AMedicaid