Provider Demographics
NPI:1407945660
Name:MARTIN, MICHAEL D (DMD, MSD, PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DMD, MSD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1959 NE PACIFIC ST
Mailing Address - Street 2:PO BOX 357131
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98195-0001
Mailing Address - Country:US
Mailing Address - Phone:206-685-2937
Mailing Address - Fax:206-616-8577
Practice Address - Street 1:1959 NE PACIFIC ST
Practice Address - Street 2:HSB - B221
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-0001
Practice Address - Country:US
Practice Address - Phone:206-685-2937
Practice Address - Fax:206-616-8577
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00006376122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5011457Medicaid
WA143783OtherL AND I
WA5011457Medicaid
WAU61172Medicare UPIN