Provider Demographics
NPI:1073633988
Name:MARTIN, STEPHANIE LYNN (DDS)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYNN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1927 BROAD RIPPLE AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220
Mailing Address - Country:US
Mailing Address - Phone:317-257-9103
Mailing Address - Fax:317-257-0931
Practice Address - Street 1:1927 BROAD RIPPLE AVENUE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220
Practice Address - Country:US
Practice Address - Phone:317-257-9103
Practice Address - Fax:317-257-0931
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ININ12009976122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200328940Medicaid