Provider Demographics
NPI:1114093937
Name:MARTIN, JB IV (DDS)
Entity Type:Individual
Prefix:DR
First Name:JB
Middle Name:
Last Name:MARTIN
Suffix:IV
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3120 KILN CREEK PKWY STE P
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23693-5648
Mailing Address - Country:US
Mailing Address - Phone:757-369-1754
Mailing Address - Fax:757-234-8891
Practice Address - Street 1:446 EFFINGHAM ST FL 1
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704-3464
Practice Address - Country:US
Practice Address - Phone:757-224-3006
Practice Address - Fax:757-234-8891
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA76031223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008200025Medicaid
003366225OtherUNITED CONCORDIA
003366242OtherUNITED CONCORDIA