Provider Demographics
NPI:1225188931
Name:MARTIN, THEODORE H (DMD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:H
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:T.
Other - Middle Name:H
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:PO BOX 815
Mailing Address - Street 2:208 N. WALNUT STREET
Mailing Address - City:SENECA
Mailing Address - State:SC
Mailing Address - Zip Code:29679-0815
Mailing Address - Country:US
Mailing Address - Phone:864-882-2372
Mailing Address - Fax:864-886-0063
Practice Address - Street 1:208 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678-2724
Practice Address - Country:US
Practice Address - Phone:864-882-2372
Practice Address - Fax:864-886-0063
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC36611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
803157OtherDELTA DENTAL OF PA
5532-1OtherDENTAL BENEFIT PROVIDERS
Z97805OtherBCBS OF MA
SCZX3661Medicaid