Provider Demographics
NPI:1346415783
Name:MARTIN A. DETTMER, D.D.S.
Entity Type:Organization
Organization Name:MARTIN A. DETTMER, D.D.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:DETTMER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-665-5550
Mailing Address - Street 1:531 E ROOSEVELT RD
Mailing Address - Street 2:STE. 100
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-5583
Mailing Address - Country:US
Mailing Address - Phone:630-665-5550
Mailing Address - Fax:
Practice Address - Street 1:531 E ROOSEVELT RD
Practice Address - Street 2:STE. 100
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-5583
Practice Address - Country:US
Practice Address - Phone:630-665-5550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-27
Last Update Date:2008-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19A14036261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental