Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | 357774-9922 | UT |
NPI | 1033274709 |
---|---|
Provider Name | Dr. Justin Dane Thornton |
First Address | Logan, UT 84341-2406 |
Second Address | Logan, UT 84341-2406 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/12/2006 |
Last Update Date | 08/07/2007 |