Provider Demographics
NPI:1134746464
Name:TOMACK, JUSTIN LEWIS (DMD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:LEWIS
Last Name:TOMACK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 S MAIN ST STE 101
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-5012
Mailing Address - Country:US
Mailing Address - Phone:919-841-1720
Mailing Address - Fax:
Practice Address - Street 1:1725 S MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-5012
Practice Address - Country:US
Practice Address - Phone:919-841-1720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-02
Last Update Date:2023-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1858766122300000X
NC124631223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist