Provider Demographics
NPI:1346415940
Name:MARTIN, ROGER PAUL (DENTURIST)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:PAUL
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DENTURIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 MOORE STREET
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04943
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:38 MOORE STREET
Practice Address - Street 2:
Practice Address - City:HARTLAND
Practice Address - State:ME
Practice Address - Zip Code:04943
Practice Address - Country:US
Practice Address - Phone:207-938-5870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME50011122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME50011OtherSTATE LIC