Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | D2731 | AZ |
NPI | 1013020502 |
---|---|
Provider Name | Dr. Bryce E. Justesen |
First Address | Mesa, AZ 85203 |
Second Address | Mesa, AZ 85213-5430 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/08/2006 |
Last Update Date | 08/07/2007 |