Provider Demographics
NPI:1184857419
Name:CHURCH, JUSTIN (DMD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:CHURCH
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 1:2540 S 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-7286
Mailing Address - Country:US
Mailing Address - Phone:480-206-0139
Mailing Address - Fax:
Practice Address - Street 1:2540 S 4TH AVE
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-7286
Practice Address - Country:US
Practice Address - Phone:480-206-0139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-03
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD 78921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice