Provider Demographics
NPI:1447412580
Name:MARTIN, BRENT ERICKSON (DMD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:ERICKSON
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 E LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:WA
Mailing Address - Zip Code:98944-2478
Mailing Address - Country:US
Mailing Address - Phone:509-837-4022
Mailing Address - Fax:509-839-4022
Practice Address - Street 1:1721 E LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:WA
Practice Address - Zip Code:98944-2478
Practice Address - Country:US
Practice Address - Phone:509-837-7178
Practice Address - Fax:509-837-3117
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60029611122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5057039Medicaid
WADE60029611OtherWASHINGTON STATE DENTAL LICENSE