Provider Demographics
NPI:1043363757
Name:AVERILL, MARTIN E (DDS)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:E
Last Name:AVERILL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2102 KIMBALL AVE
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-5037
Mailing Address - Country:US
Mailing Address - Phone:319-233-3506
Mailing Address - Fax:319-233-1335
Practice Address - Street 1:2102 KIMBALL AVE
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702-5037
Practice Address - Country:US
Practice Address - Phone:319-233-3506
Practice Address - Fax:319-233-1335
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA63161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0004572Medicaid