Provider Demographics
NPI:1124364344
Name:MACLEOD-MARTIN, MARLA JEAN (RDA,EFDA CERTIFIED)
Entity Type:Individual
Prefix:
First Name:MARLA
Middle Name:JEAN
Last Name:MACLEOD-MARTIN
Suffix:
Gender:F
Credentials:RDA,EFDA CERTIFIED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 ROCKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:STEVENSON
Mailing Address - State:WA
Mailing Address - Zip Code:98648-6423
Mailing Address - Country:US
Mailing Address - Phone:509-427-5582
Mailing Address - Fax:
Practice Address - Street 1:14406 NE 20TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-1448
Practice Address - Country:US
Practice Address - Phone:360-571-3139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-14
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAA10895126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant