Provider Demographics
NPI:1265954754
Name:KURTZ, JUSTIN ROBIN (DDS)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ROBIN
Last Name:KURTZ
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 1:4000 PARKMEAD DR STE 300
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-4908
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4000 PARKMEAD DR SUITE 300
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123-4312
Practice Address - Country:US
Practice Address - Phone:614-875-6357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-17
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH025109122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty