Provider Demographics
NPI:1013020502
Name:JUSTESEN, BRYCE E (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRYCE
Middle Name:E
Last Name:JUSTESEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:946 E. HACKAMORE
Mailing Address - Street 2:ST.
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203
Mailing Address - Country:US
Mailing Address - Phone:480-835-5945
Mailing Address - Fax:480-890-2176
Practice Address - Street 1:2830 E BROWN RD
Practice Address - Street 2:SUITE 6
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85213-5430
Practice Address - Country:US
Practice Address - Phone:480-835-5945
Practice Address - Fax:480-890-2176
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD2731122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist