Provider Demographics
NPI:1013083427
Name:JONES, JUSTIN L (DDS)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:L
Last Name:JONES
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 1:150 NE KENNETH FORD DR
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-1042
Mailing Address - Country:US
Mailing Address - Phone:541-672-9596
Mailing Address - Fax:
Practice Address - Street 1:150 NE KENNETH FORD DR
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-1042
Practice Address - Country:US
Practice Address - Phone:541-672-9596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5901122300000X
TX26305122300000X
ORD114361223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200089560AMedicaid