Provider Demographics
NPI:1043644685
Name:JUSTICE, KATHINA (RDH, AS)
Entity type:Individual
Prefix:MRS
First Name:KATHINA
Middle Name:
Last Name:JUSTICE
Suffix:
Gender:F
Credentials:RDH, AS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1896 NE LUCY BELLE ST
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-9259
Mailing Address - Country:US
Mailing Address - Phone:503-435-9542
Mailing Address - Fax:
Practice Address - Street 1:1896 NE LUCY BELLE ST
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-9259
Practice Address - Country:US
Practice Address - Phone:503-435-9542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-31
Last Update Date:2013-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH6511124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist