Provider Demographics
NPI:1003155011
Name:MARTIN, BENJAMIN JOHN (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:JOHN
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 S DENTON TAP RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-5038
Mailing Address - Country:US
Mailing Address - Phone:801-318-5003
Mailing Address - Fax:
Practice Address - Street 1:220 S DENTON TAP RD
Practice Address - Street 2:SUITE 203
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-5038
Practice Address - Country:US
Practice Address - Phone:972-393-5550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-11
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX298651223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics