Basic Information
Provider Information | |||||||||
NPI: | 1821564345 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WALDRON | ||||||||
FirstName: | JUSTIN | ||||||||
MiddleName: | CODY | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DDS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2D DENBN/NDC | ||||||||
Address2: | PSC 20130 315 MCHUGH BLVD | ||||||||
City: | CAMP LEJEUNE | ||||||||
State: | NC | ||||||||
PostalCode: | 285420130 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9104512208 | ||||||||
FaxNumber: | 9104518036 | ||||||||
Practice Location | |||||||||
Address1: | 1ST DENBN/ NDC | ||||||||
Address2: |   | ||||||||
City: | CAMP PENDLETON | ||||||||
State: | CA | ||||||||
PostalCode: | 920555221 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7607255419 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/23/2018 | ||||||||
LastUpdateDate: | 04/15/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/01/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 103184 | CA | Y |   | Dental Providers | Dentist |   |
No ID Information.