Provider Demographics
NPI:1083699086
Name:MARTIN, BRIAN CALVIN (DDS)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:CALVIN
Last Name:MARTIN
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 1:622 EAGLE ROCK AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-2994
Mailing Address - Country:US
Mailing Address - Phone:973-325-1011
Mailing Address - Fax:973-325-1183
Practice Address - Street 1:622 EAGLE ROCK AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-2994
Practice Address - Country:US
Practice Address - Phone:973-325-1011
Practice Address - Fax:973-325-1183
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-13
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI0216731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice