Provider Demographics
NPI:1417258260
Name:GEORGE, MARTIE ANN (RDH)
Entity Type:Individual
Prefix:
First Name:MARTIE
Middle Name:ANN
Last Name:GEORGE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 RICHARD DR
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16509-2977
Mailing Address - Country:US
Mailing Address - Phone:814-866-1401
Mailing Address - Fax:
Practice Address - Street 1:902 RICHARD DR
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-2977
Practice Address - Country:US
Practice Address - Phone:814-866-1401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-10
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADH068878124Q00000X
PAPHDH000121124Q00000X
NY024762-1124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist