Provider Demographics
NPI:1053939629
Name:JUSTIN E TARVER DDS APDC
Entity type:Organization
Organization Name:JUSTIN E TARVER DDS APDC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:E
Authorized Official - Last Name:TARVER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:318-343-6006
Mailing Address - Street 1:92 LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-4262
Mailing Address - Country:US
Mailing Address - Phone:318-343-6006
Mailing Address - Fax:
Practice Address - Street 1:92 LINCOLN RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-4262
Practice Address - Country:US
Practice Address - Phone:318-343-6006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-10
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1858781Medicaid