Provider Demographics
NPI:1275742280
Name:MARTIN, GABRIEL WILEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:GABRIEL
Middle Name:WILEY
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 1:1621 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-3502
Mailing Address - Country:US
Mailing Address - Phone:804-337-4146
Mailing Address - Fax:
Practice Address - Street 1:130 THOMPSON ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:VA
Practice Address - Zip Code:23005-1526
Practice Address - Country:US
Practice Address - Phone:804-798-2776
Practice Address - Fax:804-798-3110
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014114751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice