Provider Demographics
NPI:1033550785
Name:LAND, MARTIN F (DDS, MSD)
Entity Type:Individual
Prefix:PROF
First Name:MARTIN
Middle Name:F
Last Name:LAND
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 COLLEGE AVE - BLDG. 284
Mailing Address - Street 2:SOUTHERN ILLINOIS UNIVERSITY, SCHOOL OF DENTAL MEDICINE
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-4700
Mailing Address - Country:US
Mailing Address - Phone:618-474-7072
Mailing Address - Fax:618-474-7141
Practice Address - Street 1:2800 COLLEGE AVE - BLDG. 263
Practice Address - Street 2:SOUTHERN ILLINOIS UNIVERSITY, SCHOOL OF DENTAL MEDICINE
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-4700
Practice Address - Country:US
Practice Address - Phone:618-474-7072
Practice Address - Fax:618-474-7141
Is Sole Proprietor?:No
Enumeration Date:2013-07-10
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0214471223G0001X
FLDN85611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice