Active NPI
Justin Mackert, DMD
- General Practice Dentistry
- Lakewood, OH
National Provider Identifier
1528685369
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- 30.026215
- Practice address
- 15711 Madison Ave Ste 104
Lakewood, OH 44107-5655 - Phone
- (440) 823-3175
- Fax
- (216) 228-7951
- NPI assigned
- Jun 27, 2020
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 30.026215 | OH | Primary |
Addresses
Primary practice location
15711 Madison Ave Ste 104
Lakewood, OH 44107-5655
Mailing address
15711 Madison Ave Ste 104
Lakewood, OH 44107-5655
Phone (440) 823-3175
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 30.026215 | Other | OH | DENTAL LICENSE |
Electronic endpoints 1
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| CONNECT URL | lakewood15711@gmail.com | Direct |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in OH
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20200901003210 | OH | Order and Referring Only - Dentist | 7911324223 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 30.026215 | OH | MD | General Practice Dentistry |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1593216000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1593216000000",
"number": "1528685369",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "15711 MADISON AVE STE 104",
"city": "LAKEWOOD",
"state": "OH",
"postal_code": "441075655",
"telephone_number": "440-823-3175"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "15711 MADISON AVE STE 104",
"city": "LAKEWOOD",
"state": "OH",
"postal_code": "441075655",
"telephone_number": "440-823-3175",
"fax_number": "216-228-7951"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MACKERT",
"first_name": "JUSTIN",
"credential": "DMD",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2020-06-27",
"last_updated": "2020-06-27",
"certification_date": "2020-06-27",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "OH",
"license": "30.026215",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "DENTAL LICENSE",
"identifier": "30.026215",
"state": "OH"
}
],
"endpoints": [
{
"endpointType": "CONNECT",
"endpointTypeDescription": "CONNECT URL",
"endpoint": "lakewood15711@gmail.com",
"affiliation": "N",
"endpointDescription": "lakewood@gmail.com",
"use": "DIRECT",
"useDescription": "Direct",
"contentType": "CSV",
"contentTypeDescription": "CSV",
"address_1": "15711 Madison Ave Ste 104",
"city": "Lakewood",
"state": "OH",
"country_code": "US",
"postal_code": "441075655",
"country_name": "United States",
"address_type": "DOM"
}
],
"other_names": []
}Other providers in Lakewood, OH
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 27, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.