Provider Demographics
NPI:1154819043
Name:MARTIN, ALAN J
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:J
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:690 WILD CYPRESS CIR
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32081-5731
Mailing Address - Country:US
Mailing Address - Phone:904-829-1962
Mailing Address - Fax:904-395-3489
Practice Address - Street 1:268 HERBERT ST
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-4000
Practice Address - Country:US
Practice Address - Phone:904-829-1962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-25
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN230101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice