Provider Demographics
NPI:1861703829
Name:VALENTINE, JUSTIN RANDOLPH (DDS)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:RANDOLPH
Last Name:VALENTINE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6934 BEACH DR SW
Mailing Address - Street 2:
Mailing Address - City:OCEAN ISLE BEACH
Mailing Address - State:NC
Mailing Address - Zip Code:28469-5797
Mailing Address - Country:US
Mailing Address - Phone:910-777-8660
Mailing Address - Fax:
Practice Address - Street 1:6934 BEACH DR SW
Practice Address - Street 2:
Practice Address - City:OCEAN ISLE BEACH
Practice Address - State:NC
Practice Address - Zip Code:28469-5797
Practice Address - Country:US
Practice Address - Phone:804-475-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-24
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9004122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004011136Medicaid