Provider Demographics
NPI:1003289273
Name:MARTIN, CAROL (RDH, PHDHP, BSDH)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RDH, PHDHP, BSDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 LAURIE LN
Mailing Address - Street 2:
Mailing Address - City:LITITZ
Mailing Address - State:PA
Mailing Address - Zip Code:17543-8106
Mailing Address - Country:US
Mailing Address - Phone:717-627-0811
Mailing Address - Fax:
Practice Address - Street 1:22 LAURIE LN
Practice Address - Street 2:
Practice Address - City:LITITZ
Practice Address - State:PA
Practice Address - Zip Code:17543-8106
Practice Address - Country:US
Practice Address - Phone:717-627-0811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-09
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPHDH000046124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist