Provider Demographics
NPI:1003821893
Name:MARTINSONDRISCOLL D.D.S.
Entity Type:Organization
Organization Name:MARTINSONDRISCOLL D.D.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:JO
Authorized Official - Last Name:SWENOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-347-7471
Mailing Address - Street 1:2050 M 119
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-8962
Mailing Address - Country:US
Mailing Address - Phone:231-347-7471
Mailing Address - Fax:231-347-7836
Practice Address - Street 1:2050 M 119
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8962
Practice Address - Country:US
Practice Address - Phone:231-347-7471
Practice Address - Fax:231-347-7836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID811511OtherBLUE CROSS BLUE SHIELD