Provider Demographics
NPI:1881255966
Name:DISTELRATH, JUSTIN
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:DISTELRATH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1795 W STADIUM BLVD
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-5290
Mailing Address - Country:US
Mailing Address - Phone:734-677-8700
Mailing Address - Fax:734-839-4137
Practice Address - Street 1:1795 W STADIUM BLVD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-5290
Practice Address - Country:US
Practice Address - Phone:734-677-8700
Practice Address - Fax:734-839-4137
Is Sole Proprietor?:No
Enumeration Date:2019-06-27
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010232051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice