Provider Demographics
NPI:1073108890
Name:MARTIN DENTAL
Entity Type:Organization
Organization Name:MARTIN DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAYLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:CRAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-672-2453
Mailing Address - Street 1:1815 S CRISMON RD
Mailing Address - Street 2:104
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209
Mailing Address - Country:US
Mailing Address - Phone:480-672-2453
Mailing Address - Fax:480-672-2454
Practice Address - Street 1:1815 S CRISMON RD
Practice Address - Street 2:104
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-8520
Practice Address - Country:US
Practice Address - Phone:480-672-2453
Practice Address - Fax:480-672-2454
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARTIN DENTAL-AIRPARK LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-03-03
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1457702607OtherGENERAL DENTISTRY