Provider Demographics
NPI:1336133446
Name:MARTIN, RICHARD J (MD, DMD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:J
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MD, DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 SACHEM ST
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-4144
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:159 SACHEM ST
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-4144
Practice Address - Country:US
Practice Address - Phone:860-885-0444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-02
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT007905204E00000X
CT0364722086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTHO6445Medicare UPIN